1.
Are
physicians who practice in hospital-based ambulatory clinics eligible to
receive Medicare or Medicaid electronic health record (EHR) incentive payments?
Ans: A hospital-based
eligible professional (EP) is defined as an EP who furnishes 90 percent or more
of his/her services in either the inpatient or emergency department of a
hospital. Hospital-based EPs do not qualify for Medicare or Medicaid EHR
incentive payments.
If you are a new EP and need to
determine your hospital-based status, contact the EHR information center at
(888)734-6433 and choose option 4 in the interactive voice response system
(IVR). You will need your National Provider Identifier (NPI) and the last 5
digits of your Tax Identification Number (TIN). If you are an existing EP,
review and resubmit your registration on the Registration & Attestation website to
determine your hospital based status.
2. What
steps do eligible hospitals need to take to meet the specialized registry
objective? Is it different from EPs?
Ans: For an eligible hospital, the process is
the same as for an EP. However, we note that eligible hospitals do not need to
explore every specialty society with which their hospital-based specialists may
be affiliated. The hospital may simply check with the jurisdiction and
any such organization with which it is an affiliate, if no such organization
exists, and if their jurisdiction has no registry, they may simply exclude from
the measure.
3. Are Healthcare Common
Procedure Coding System (HCPCS) codes Q2035 and Q2039 payable by Medicare?
Ans: Effective
for claims with dates of service on or after October 1, 2010, Q2035 and Q2039
are payable by Medicare. However, the codes will not be recognized by the
Medicare claims processing systems until January 1, 2011. Since no national
payment limits are available for Q2035 or Q2039, payment limits will be
determined by the local claims processing contractor.
4. Which site of service code should be reported when a hospice
patient resides in a hospice facility and is receiving the routine home care
(RHC) or continuous home care (CHC) level of care?
Ans: When recording the site of service for a hospice
patient who is receiving RHC and residing in a hospice inpatient facility,
please code the location as Q5006. When recording the site of service for a
hospice patient who is receiving RHC or CHC and residing in a hospice
residential facility, please code the location as Q5009. This instruction may
change in the future as we are considering adding a new site of service code
for hospice home care provided in hospice facilities.
5. What is a Medically Unlikely Edit?
Ans: An MUE (Medically Unlikely Edit) is
a unit of service (UOS) edit for a Healthcare Common Procedure Coding System
(HCPCS)/Current Procedural Terminology (CPT) code for services rendered by a
single provider/supplier to a single beneficiary on the same date of service.
The ideal MUE is the maximum UOS that would be reported for a HCPCS/CPT code on
the vast majority of appropriately reported claims. MUEs are adjudicated either
as claim line edits or date of service edits. The MUE program provides a method
to report medically reasonable and necessary UOS in excess of an MUE for MUEs
that are adjudicated as claim line edits. If an MUE is adjudicated as a claim line edit or a date of service
edit, UOS in excess of the MUE value may be paid during the appeal process.
6. What modifiers are allowed with the National Correct Coding
Initiative (NCCI) edits?
Ans: The following modifiers are allowed
with the National Correct Coding Initiative (NCCI) edits:
Anatomic modifiers: E1-E4, FA,
F1-F9, TA, T1-T9, LT, RT, LC, LD, RC
Global surgery modifiers: 25, 58,
78, 79
Other modifiers: 27, 59, 91
Refer to Chapter I of the National Correct Coding Initiative Policy Manual
for Medicare Services for changes in this list of NCCI-associated modifiers.
7. How do I report medically reasonable and necessary units of
service in excess of a Medically Unlikely Edit (MUE) value?
Ans: For MUEs that are adjudicated as claim line edits,
each line of a claim is adjudicated separately against the MUE value for the
code on that line. The appropriate use of HCPCS/Current Procedural Terminology
(CPT) modifiers to report the same code on separate lines of a claim will
enable a provider/supplier to report medically reasonable and necessary units
of service in excess of an MUE value. CPT modifiers such as -76 (repeat
procedure by same physician), -77 (repeat procedure by another physician),
anatomic modifiers (e.g., RT, LT, F1, F2), -91 (repeat clinical diagnostic
laboratory test), and -59 (distinct procedural service) will accomplish this
purpose. Modifier -59 should be utilized only if no other modifier describes
the service. For MUEs that are adjudicated as date of service edits, units of
service (UOS) in excess of the MUE value may be paid during the appeal process.
8. What is the column 1/column 2 correct coding edit table?
Ans: The column 1/column 2 correct coding edit table
contains two types of code pair edits. One type contains a column 2 (previously
called component) code which is an integral part of the column 1 (previously
called comprehensive) code. The other type contains code pairs that should not
be reported together where one code is assigned as the column 1 code and the
other code is assigned as the column 2 code. If two codes of a code pair edit
are billed by the same provider for the same beneficiary for the same date of
service without an appropriate modifier, the column 1 code is paid. If clinical
circumstances justify appending a National Correct Coding Initiative-associated
modifier to the column 2 code of a code pair edit, payment of both codes may be
allowed if the modifier indicator is "1".
9. May an Advanced Beneficiary Notice (ABN) be utilized to bill
the beneficiary for services denied due to a Medically Unlikely Edit (MUE)?
Ans: No, a provider/supplier may not issue an Advanced
Beneficiary Notice (ABN) for units of service in excess of an Medically
Unlikely Edit (MUE). Furthermore, if services are denied based on an MUE, an
ABN cannot be used to shift liability and bill the beneficiary for the denied
services. It is a provider/supplier liability.
10. How do I request a change in the Medically Unlikely Edit
(MUE) value for a Healthcare Common Procedure Coding System (HCPCS)/Current
Procedural Terminology (CPT) code?
Ans: If a provider/supplier, healthcare
organization, or other interested party believes that an Medically Unlikely
Edit (MUE) value should be modified, it may write Correct Coding solutions, LLC
at the address below. The party should include its rationale and any supporting
documentation. However, it is generally recommended that the party contact the
national healthcare organization whose members perform the procedure prior to
writing to Correct Coding Solutions, LLC. The national healthcare organization
may be able to clarify the reporting of the code in question. If the national
healthcare organization agrees that the MUE value should be modified, its
support and assistance may be helpful in requesting the modification of an MUE
value.
Requests for modification of an MUE
value should be sent to the following:
National Correct Coding Initiative
Correct Coding Solutions, LLC
P.O. Box 907
Carmel, IN 46082-0907
FAX: 317-571-1745
Correct Coding Solutions, LLC
P.O. Box 907
Carmel, IN 46082-0907
FAX: 317-571-1745
11. How often are the National Correct Coding Initiative (NCCI)
edits updated?
Ans: The National Correct Coding Initiative (NCCI) edits
are usually updated on a quarterly basis. Note that the NCCI edits are included
in the Outpatient Code Editor (OCE). Under the hospital
Outpatient Prospective Payment System (OPPS), the NCCI edits are no longer
one version behind.
12. Has CMS published the Medically Unlikely Edit (MUE) values
for Healthcare Common Procedure Coding System (HCPCS)/Current Procedural
Terminology (CPT) codes?
Ans: CMS publishes on its website most
Medically Unlikely Edit (MUE) values. However, CMS does not publish MUE values
for some codes. The MUE values for this latter group of codes are confidential
information that should not be published by third parties who have acquired
them.
MUE values are not utilization
guidelines. Providers may be subject to a review of their claims by claims
processing contractors, program safeguard contractors (PSCs), or recovery audit
contractors (RACs) even if they report units of service less than or equal to
the MUE value for a Healthcare Common Procedure Coding System (HCPCS) code.
13. Is there an appeal process for claim lines denied based on
Medically Unlikely Edits (MUEs)?
Ans: Since
claim lines are denied at Carriers and Part A/Part B Medicare Administrative
Contractors (A/B MACs) processing claims with the MCS system and at Durable
Medical Equipment Medicare Administrative Contractors (DME MACs) processing
claims with the VMS system, Medically Unlikely Edits (MUE)-based claim line
denials at these contractors may be appealed.
However, at
Fiscal Intermediaries (FIs) and A/B MACs processing claims with the Fiscal
Intermediary Shared System (FISS), claims with a claim line with units of
service exceeding an MUE value are returned to the provider. No claim denial
occurs, and appeals are not available.
Appeals should
be submitted to local contractors not the MUE contractor, Correct Coding
Solutions, LLC.
14. What is the definition of "new patient" for
billing evaluation and management (E/M) services?
Ans: Interpret the phrase "new patient" to
mean a patient who has not received any professional services, i.e., evaluation
and management service or other face-to-face service (e.g., surgical procedure)
from the physician or physician group practice (same physician specialty)
within the previous three years.
For example, if a professional component of a
previous procedure is billed in a 3-year time-period, e.g., a lab
interpretation is billed and no E/M service or other face-to-face service with
the patient is performed, then this patient remains a new patient for the
initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG
etc., in the absence of an E/M service or other face-to-face service with the
patient does not affect the designation of a new patient.
Beginning in 2012,
the AMA CPT instructions for billing new patient visits include physicians in
the same specialty and subspecialty. However, for Medicare E/M services the
same specialty is determined by the physician's or practitioner's primary
specialty enrollment in Medicare. Recognized Medicare specialties can be found
in the Medicare Claims Processing Manual, chapter 26 (http://www.cms.gov/manuals/downloads/clm104c26.pdf). You may contact
your Medicare claims processing contractor to confirm your primary Medicare
specialty designation.
15. Will my payment under ICD-10 be the same as the payment I
currently receive under ICD-9?
Hospitals - A fiscal year
2015 study conducted on the impact of converting Medicare Severity Diagnosis
Related Groups (MS-DRGs) to ICD-10 found that moving from an ICD-9-CM-based
system to an ICD-10 MS-DRG replicated system resulted in a statistically zero
impact on payment. Ninety-nine percent of the records did not shift to another
MS-DRG when using an ICD-10 MS-DRG system. For the 1 percent of records that
shifted, 41 percent were to a higher weighted MS-DRG and 66 percent were to a
lower weighted MS-DRG. The net impact across all MS-DRGs was a reduction by
4/10000 or minus 4 cents per $100, which is statistically zero impact. For more
information about this study, refer to Converting MS-DRGs to ICD-10-CM and
ICD-10-PCS Updated 03/03/15 With New 2015 Impact Article located in the
Downloads section at :http://http://cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html on
the CMS website.
Professional and supplier claims -
Payment is based on the Healthcare Common Procedure Coding System (HCPCS) code
and under ICD-10-CM, payment will also be based on the HCPCS code. A claim
could be denied if the diagnosis does not warrant payment for the procedure.
You should consult the appropriate payment policy, National Coverage
Determination (NCD), or Local Coverage Determination (LCD) pertaining to the
service you wish to bill to determine whether there are any changes to
diagnosis code reporting requirements. You should also consult the 2015 payment
rules and the forthcoming 2016 payment rules for ICD-10-CM impacts.
16. What procedures and services are payable when performed in
the Ambulatory Surgical Center (ASC) setting under the revised ASC payment
system?
Ans: Under the ASC payment system, Medicare will make
facility payments to ASCs only for the specific ASC covered surgical procedures
on the ASC list of covered surgical procedures published in Addendum AA of the
hospital outpatient prospective payment system (OPPS)/ASC final rule for the
relevant payment year. Addendum AA to the calendar year (CY) 2008 OPPS/ASC
final rule is available at http://www.cms.hhs.gov/ASCPayment/ASCRN/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=3&sortOrder=descending&itemID=CMS1213395&intNumPerPage=10. In addition,
Medicare will make separate payment to ASCs for certain covered ancillary
services that are provided integral to a covered ASC surgical procedure.
Covered ancillary services include the following:
• Brachytherapy sources;
• Certain implantable items with pass-through status under the OPPS;
• Certain items and services that CMS designates as contractor-priced, including, but not limited to, the procurement of corneal tissue;
• Certain drugs and biologicals for which separate payment is allowed under the OPPS; and
• Certain radiology services for which separate payment is allowed under the OPPS.
Other non-ASC services such as physician services and prosthetic devices may be covered and separately billed under Medicare Part B. See the Medicare Claims Processing Manual, Chapter 14, Section 10.2 for more information.
• Brachytherapy sources;
• Certain implantable items with pass-through status under the OPPS;
• Certain items and services that CMS designates as contractor-priced, including, but not limited to, the procurement of corneal tissue;
• Certain drugs and biologicals for which separate payment is allowed under the OPPS; and
• Certain radiology services for which separate payment is allowed under the OPPS.
Other non-ASC services such as physician services and prosthetic devices may be covered and separately billed under Medicare Part B. See the Medicare Claims Processing Manual, Chapter 14, Section 10.2 for more information.
17. If patients have recurring appointments for physical
therapy, occupational therapy, or speech-language pathology services that will
continue after ICD-10 implementation, will new orders with ICD-10 codes be
required?
Ans: In cases where physician or qualified non-physician
practitioner orders are applicable to rehabilitation services furnished under
CMS programs, CMS is not requiring updated orders to continue rehabilitation
services after ICD-10 implementation on October 1, 2015; however, these claims
must contain a valid ICD-10 diagnosis code. Physicians will need to provide the
appropriate ICD-10 code to the therapist for these claims. Orders created after
the transition to ICD-10 must use ICD-10 codes.
