FAQs Updated

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

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.

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. 

Interventional radiology sees many code changes in 2016

Interventional radiology sees many code changes in 2016

February 9, 2016 -- Compliance with changes for the coding of interventional radiology procedures made by the American Medical Association (AMA) and the U.S. Centers for Medicare and Medicaid Services (CMS) for 2016 may be a challenge for some radiologists and coding professionals

This is especially true for a few new and revised instructions "hiding" in documents such as the January 2016 edition of the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, as well as those not hiding but not obvious at first glance. Examples of several such changes -- as well as clarifications on new coding and billing requirements -- are provided below.

Post procedure mammograms

Medicare's policy on post-procedure mammography has changed yearly since 2013 -- from not allowing it at all, to allowing it with stereotactic, ultrasound, and MR-guided procedures; and then to allowing it only with ultrasound and procedures guided by MRI. The 2016 NCCI Policy Manual has reverted back to the 2014 policy statement that allows separate coding of a post procedure mammogram with all but the mammogram-guided localization.

Chapter 9 of the policy manual includes the following statement:

11. If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with mammographic guidance (e.g., 19281, 19282), the physician should not separately report a postprocedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.

Soft-tissue marker

Occasionally, an interventional radiologist is asked to place a marker in a lesion in a location other than the breast prior to open biopsy or other surgery. Until now, an unlisted code had to be reported for these procedures. AMA added the following codes to the 2016 CPT book for the placement of soft-tissue markers such as clips, pellets, needle/wire, or radioactive seeds:

·         10035: Placement of soft-tissue localization device(s) (e.g., clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion

·         10036: Placement of soft-tissue localization device(s) (e.g., clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; each additional lesion (list separately in addition to code for primary procedure)

The most common use for the above codes would be to mark lymph nodes in the axilla and groin, although there may be other situations as well. Guidelines include the following:

·         Report 10035 for the first lesion marked.

·         If a second lesion is also marked, report add-on code 10036.

·         Report codes 10035 and 10036 only once per lesion regardless of the number of markers used.

·         Do not also assign code 76942, 77002, 77012, or 77021 since imaging guidance of any kind is included in the above.

Percutaneous sclerotherapy

In 2016, the following new code was introduced for sclerosis of a (nonvascular) fluid cavity:

·         49185: Sclerotherapy of a fluid collection (e.g., lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (e.g., ultrasound, fluoroscopy), and radiological supervision and interpretation when performed

This code includes any diagnostic injection of contrast and imaging to evaluate the cavity prior to sclerotherapy. The code also includes imaging guidance for the sclerosing procedure, injection of the sclerosant, and supervision and interpretation.

Code 49185 does not include access into the cavity, nor does it include drainage prior to sclerotherapy, if performed. Access and drainage codes such as 10160, 50390, 10030, 49405-49407, and 50390 may be reported in addition to 49185 when appropriate.

Coding tips include the following:

·         Do not also report 49424 and 76080 in addition to 49185.

·         Report 49185 once per day for each fluid cavity sclerosed through separate catheters. If multiple cavities are treated through the same catheter, report 49185 only once.

·         When a previously placed drainage catheter is replaced before or after sclerotherapy, codes 49423 and 75984 may be separately coded.

·         Use code 49185 for sclerotherapy of a lymphocele, but report embolization code 37241 for sclerotherapy of a lymphatic malformation.

Thoracic paravertebral block

Three new codes have been introduced for thoracic paraspinous blocks and infusion for pain management. These blocks may be performed instead of an epidural or subarachnoid injection for patients undergoing thoracic, breast, or upper abdominal surgery:

·         64461: Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed)

·         64462: Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance, when performed) (list separately in addition to code for primary procedure)

·         64463: Paravertebral block (PVB) (paraspinous block), thoracic; continuous infusion by catheter (includes imaging guidance, when performed)

All of the above codes include imaging guidance, when performed; do not also assign one of the modality-specific guidance codes.

Coding tips include the following:

·         Code 64461 is reported for a single injection at any thoracic level.

·         Code 64462 is reported when additional injections are performed at other thoracic levels, or on the opposite side as the initial injection. Only report code 64462 once per day, regardless of how many additional injections are performed.

·         Report 64463 when a catheter is placed into the paravertebral space and left in place for continuous infusion of an anesthetic, usually for postoperative pain management.

·         Do not report the above codes with epidural, transforaminal epidural, intercostal, or facet joint injections in the thoracic area.

Biliary system code changes

Codes for percutaneous procedures in the biliary system underwent significant revision for 2016. Most of the existing codes for procedures in the biliary system were deleted and new codes were added. Most of these new codes bundle diagnostic exams and therapeutic procedures when performed at the same session. Injections of contrast and imaging necessary to perform the therapeutic procedure should not be separately coded.

Medicare to cut analog x-ray payments starting in 2017

Medicare to cut analog x-ray payments starting in 2017

February 8, 2016 -- As part of a push to nudge U.S. healthcare providers to adopt digital radiography (DR), the Medicare system will begin reducing payments for exams performed on analog x-ray systems starting in 2017. The year after that, sites using computed radiography (CR) equipment will also see payment reductions.

Medicare payments will be reduced by 20% for providers submitting claims for analog x-ray studies starting in 2017 under a provision in the Consolidated Appropriations Act of 2016, which was enacted into law in December 2015. Starting in 2018, payments for imaging studies performed on CR equipment would be reduced by 7% for the next five years, and 10% after that.

While the law's provisions on analog x-ray are expected to have a minor impact due to the small number of traditional systems still in operation in the U.S., the reductions in CR payments could have a much broader effect: More than 8,000 CR units are still in service in the U.S. All of these systems must be replaced or imaging facilities will experience payment reductions.

Transforming the oldest modality

The adoption of DR over the past two decades has transformed medical imaging's oldest modality, enabling bread-and-butter x-ray images to be acquired quickly and then easily transferred into PACS for distribution, interpretation, and archiving. Before DR arrived, many facilities upgraded their x-ray equipment with CR, which replaced film-screen cassettes with imaging plates that can be carried to a reader for digital output.

The provisions inserted into the Consolidated Appropriations Act are designed to speed the transition of U.S. healthcare providers toward digital radiography by changing the Hospital Outpatient Prospective Payment System. Classified as a "special rule," it specifies a 20% cut starting in 2017 to the technical component of reimbursement for an x-ray taken using film.

The cuts for CR are phased in over time, starting in 2018. Payment for the technical component of an x-ray acquired using computed radiography will be reduced by 7% during the years 2018 to 2022 and by 10% after that. Complete text of the act can be viewed by clicking here.

Origins of the provision began about a year ago, when the American College of Radiology (ACR) began working with various manufacturers, in particular Varian Medical Systems, according to Cynthia Moran, ACR's executive vice president of government relations, economics, and health policy.

While Varian is best known for radiation therapy systems, it also manufactures DR panels for inclusion into new OEM x-ray systems and offers DR retrofits for installed analog and CR x-ray systems in the field.

The DR provision was originally inserted into the 21st Century Cures Act, legislation proposed in 2015 that among other things would have repealed the Multiple Procedure Payment Reduction (MPPR). The controversial MPPR rule was implemented by the U.S. Centers for Medicare and Medicaid Services (CMS) in 2012 and reduced reimbursement by 25% for imaging studies performed on the same body part on the same patient in the same imaging session.

The 21st Century Cures Act passed the House of Representatives on its own, but on arrival in the Senate many of its provisions were folded into the Consolidated Appropriations Act -- including the DR provision and a change in the MPPR from 25% to 5%, Moran said. The budget bill eventually passed with both provisions intact, she said, and was signed by President Obama.

ACR worked with vendors, including Varian and the Medical Imaging and Technology Alliance (MITA), on getting the DR provision inserted into the Consolidated Appropriations Act in exchange for their support in reducing the MPPR cut, Moran said.

"They supported us in us trying to get MPPR payment reduction passed, and so we partnered with them to go to Congress to see if they would do the two imaging provisions and handle them at one time," Moran said.

While it's tough getting any proposed legislation through Congress, Moran said the two provisions were attractive because they will save the federal government $350 million over the next 10 years. In the case of the DR provision, the savings will come from lower Medicare payments being made to hospitals operating analog and CR equipment.

Legislation's impact

How much will the legislation affect U.S. hospitals? Not much when it comes to analog x-ray, as the number of film-based systems operating in the U.S. has fallen to miniscule levels, according to market research firm IMV Medical Information Division.

In its 2013 x-ray market report, IMV projected that fixed analog general x-ray rooms made up just 1% of the installed base at U.S. hospitals, down from 5% in 2010. Indeed, the decline in the analog installed base was so great that in its 2015 report IMV didn't bother to ask radiology administrators how many analog units they were still operating, according to IMV Senior Director Lorna Young.

"So few people have film that it's not worth talking about," Young said. "I think film in the installed base has gone virtually to nothing."

CR offers a different story. While still considered digital, the technology lacks the workflow efficiency of DR, and sales have been declining over the years. While CR made up 55% of new digital x-ray sales in 2006, that number fell to just 6% in 2015, with the rest of digital x-ray sales made up by DR, according to IMV.

Still, years of strong CR installations mean that the technology still makes up a significant part of the installed base of digital x-ray systems, unlike analog x-ray, Young said. In IMV's 2015 report on the x-ray market, the firm estimated that there are 16,775 fixed general x-ray systems installed at hospitals in the U.S. (a figure that does not include mobile units or systems installed at outpatient locations). Of that total installed base, some 8,545 systems are CR.

Imaging facilities will therefore have to decide whether to spend the money to upgrade their CR equipment to DR, or swallow a 7% to 10% reduction in payments for x-ray studies. Many of these facilities are located in rural areas, with less access to the capital needed to buy new equipment.

In its 2015 x-ray market report, IMV said that 62% of hospitals were already planning to buy either a new x-ray system or a DR retrofit kit in the coming years. Of these, 70% of sites with fixed CR systems are planning purchases, Young said, while only 34% of sites with fixed DR are making purchasing plans -- perhaps indicating their satisfaction with the newer technology.

Converting to DR will produce workflow and efficiency gains -- as well as lower radiation dose -- for the U.S. hospitals that finally make the switch to fully digital operation, according to ACR's Moran.

"Clearly analog is felt to be antiquated and not helpful. CR is clearly less antiquated, much more in use, and has many advocates for it, but even that market is moving fairly quickly to digital," she said. "This policy just furthers that along."

For Varian's part, the company sees its support for the legislation as adding impetus to a positive trend in healthcare, according to Spencer Sias, vice president of communications and investor relations at the company.

"We believe that digital imaging makes it possible to lower the cost per procedure by allowing for higher throughput in imaging centers," Sias told AuntMinnie.com. "We eliminate the need to buy, process, develop, and store film. That is a very good thing in an age when the cost of medicine needs to be held in check."

Ref ; http://www.auntminnie.com/index.aspx?sec=sup&sub=xra&pag=dis&ItemID=113334