C O D I N G & B I L L I N G F O R

Transcription

1 HMI Cor poration Third Quarter 2009 September 30, 2009 C O D I N G & B I L L I N G F O R P R O S P E C T I V E P A Y M E N T S Y S T E M S October 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS) Inside This Issue: October 2009 OPPS Update New HCPCS Code Effective for Certain Drugs and Biologicals Adjustment to Status Indicator for HCPCS code Q4115 Updated Payment Rates for Certain HCPCS Codes Effectove July 1 through September 30, 2009 Clarification Related to Condition Code 44 H1N1 Vaccine and Administration Level II HCPCS Codes New Waived CLIA Tests 4 Medicare Travel Allowance Fees for Collection of Specimens Diabetes Self-Management Training 6 Fractional Mileage Amounts Submitted on Ambulance Claims Billing for an Ambulance Transport with More than One Patient Onboard Q&A Changes to Procedure and Device Edits for October 2009 Procedures to device edits require that when a particular procedural HCPCS code is billed, the claim must also contain an appropriate device code. Failure to pass these edits will result in the claim being returned to the provider. Device to procedure edits require that a claim that contains one of a specified set of device codes be returned to the provider if it fails to contain an appropriate procedure code. The updated lists of both types of edits can be found under Device, Radiolabeled Product, and Procedure Edits at Billing for Drugs, Biologicals, and Radiopharmaceuticals Hospitals are strongly encouraged to report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for the items used. It is also of great importance that hospitals billing for these products make certain that the reported units of service of the reported HCPCS codes are consistent with the quantity of a drug, biological, or radiopharmaceutical that was used in the care of the patient. We remind hospitals that under the OPPS, if two or more drugs or biologicals are mixed together to facilitate administration, the correct HCPCS codes should be reported separately for each product used in the care of the patient. The mixing together of two or more products does not constitute a "new" drug as regulated by the Food and Drug Administration (FDA) under the New Drug Application (NDA) process. In these situations, hospitals are reminded that it is not appropriate to bill HCPCS code C9399. HCPCS code C9399, Unclassified drug or biological, is for new drugs and biologicals that are approved by the FDA on or after January 1, 2004, for which a HCPCS code has not been assigned. Unless otherwise specified in the long description, HCPCS code descriptors refer to the non-compounded, FDA-approved final product. If a product is compounded and a specific HCPCS code does not exist for the compounded product, the hospital should report an appropriate unlisted code such as J9999 or J3490. Continued on page 2

2 Third Quarter 2009 Page 2 October 2009 OPPS Update cont... Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective October 1, 2009 Coding & Billing for Prospective Payment Systems Newsletter contributors and editorial board: Thomas P. Holliday, RN, PA, MHA G. Maria Caston, CCS, CPC-H, CCS-P, CPC, CPS, CFS For CY 2009, payment for nonpass-through drugs and biologicals is made at a single rate of ASP+4 percent, which provides payment for both the acquisition cost and pharmacy overhead costs associated with the drug or biological. In CY 2009, a single payment of ASP+6 percent for pass-through drugs and biologicals is made to provide payment for both the acquisition cost and pharmacy overhead costs of these pass-through items. We note that for the third quarter of CY 2009, payment for drugs and biologicals with pass-through status is not made at the Part B Drug Competitive Acquisition Program (CAP) rate, as the CAP program is suspended beginning January 1, Should the Part B Drug CAP program be reinstituted sometime during CY 2009, we would again use the Part B drug CAP rate for passthrough drugs and biologicals if they are a part of the Part B drug CAP program, as required by the statute. In the CY 2009 OPPS/ASC final rule with comment period, it was stated that payments for drugs and biologicals based on ASPs will be updated on a quarterly basis as later quarter ASP submissions become available. In cases where adjustments to payment rates are necessary based on the most recent ASP submissions, we will incorporate changes to the payment rates in the October 2009 release of the OPPS Pricer. The updated payment rates, effective October 1, 2009 will be included in the October 2009 update of the OPPS Addendum A and Addendum B, which will be posted on the CMS Web site. Mary Quimby, CPC-H, CPS, CFS Vickie Faler, RHIT, CPC New HCPCS Code Effective for Certain Drugs and Biologicals A new HCPCS code has been created for reporting drugs and biologicals in the hospital outpatient setting for October HCPCS code Q2024 is listed in Table 1 below and is effective for services furnished on or after October 1, This HCPCS code is assigned status indicator K, to indicate separate payment may be made for the product. Table 1- New HCPCS Code Effective for Certain Drugs and Biologicals Effective October 1, 2009 HCPCS Code Q2024 Long Descriptor Injection, Bevacizum ab, 0.25 mg APC Status Indicator Effective 10/1/ K Continued on page 3

3 Third Quarter 2009 Page 3 October 2009 OPPS Update cont... Adjustment to Status Indicator for HCPCS code Q4115 Effective October 1, 2009 CMS assigned HCPCS code Q4115, Skin substitute, alloskin, per square centimeter, a status indicator of M for services billed on or after July 1, 2009 through September 30, 2009, indicating that the service is not billable to the FI/MAC. For services furnished on or after October1, 2009, CMS is changing the status indicator for Q4115 to K to indicate that separate payment may be made for this product. HCPCS code Q4115 is assigned to APC 1287 (Alloskin skin sub). Updated Payment Rates for Certain HCPCS Codes Effective July 1, 2009 through September 30, 2009 The payment rates for several HCPCS codes were incorrect in the July 2009 OPPS Pricer. The corrected payment rates are listed in Table 5 below and have been installed in the October 2009 OPPS Pricer, effective for services furnished on July 1, 2009, through implementation of the October 2009 update. Table 5-Updated Payment Rates for Certain HCPCS Codes Effective July 1, 2009 through September 30, 2009 HCPCS Code Status Indicator APC Short Descriptor K 9137 Bcg vaccine, percut C9359 G 9359 Implnt,bon void fillerputty J9031 K 0809 Bcg live intravesical vac J9211 K 0832 Idarubicin hcl injection J9265 K 0863 Paclitaxel injection J9293 K 0864 Mitoxantrone hydrochl / 5 MG Q0179 K 0769 Ondansetron hcl 8 mg oral Corrected Payment Rate Corrected Minimum Unadjusted Copayment $ $23.09 $65.21 $12.80 $ $22.95 $ $25.22 $7.62 $1.52 $66.26 $13.25 $7.91 $1.58 Clarification Related to Condition Code 44 The changes to Pub , Medicare Claims Processing Manual, Chapter 1, section 50.3, incorporate minor revisions clarifying the use of Condition Code 44. The conditions for the use of Condition Code 44, as stated in section below, require physician concurrence with the UR committee decision. For Condition Code 44 decisions, in accordance with 42 CFR (d)(1), one physician member of the UR committee may make the determination for the committee that the inpatient admission is not medically necessary. This physician member of the UR committee must be a different person from the concurring physician, who is the physician responsible for the care of the patient. Continued on page 4

4 Third Quarter 2009 Page 4 H1N1 Vaccine and Administration Level II HCPCS Codes In anticipation of the availability of a vaccine for the H1N1 virus in the fall of 2009, CMS is creating two new Level II HCPCS codes. Similar to the influenza vaccine and its administration, one HCPCS code has been created to describe the H1N1 vaccine itself (G9142, Influenza A (H1N1) vaccine, any route of administration), while another HCPCS code has been created to describe the administration of the H1N1 vaccine (G9141, Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)). More information on the H1N1 flu and the associated vaccine can be found at the Centers for Disease Control and Prevention website at Under the OPPS, HCPCS code G9142 will be assigned status indicator E, indicating that payment will not be made by Medicare when this code is submitted on an outpatient bill type because we anticipate that the H1N1 vaccine will be supplied at no cost to providers. Payment will be made to a provider for the administration of the H1N1 vaccine, even if the vaccine is supplied at no cost to the provider. Beneficiary copayment and deductible do not apply to HCPCS code G9141 (for both OPPS and non OPPS providers), and we are assigning HCPCS code G9141 to APC 0350 (Administration of Flu and PPV Vaccine) with a payment rate of $24.89 for CY Providers should report one unit of HCPCS code G9141 for each administration of the H1N1 vaccine. The effective date of G9141 and G9142 is September 1, This effective date is earlier than originally anticipated, and therefore, the effective date reflected in the October IOCE will be October 1, For the January IOCE release, we will change the effective date for these HCPCS to be retroactive to September 1, Claims containing G9141 and G9142 with dates of service on or after September 1, 2009 but prior to October 1, 2009 will be held until the successful installation of the January IOCE release. Additional information will be made available to contractors through a separate CR. To read the full October OPPS update transmittal go to New Waived Tests Transmittal 1799 dated August 21, 2009 The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to be appropriately certified for each test performed. To ensure that Medicare & Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, laboratory claims are currently edited at the CLIA certificate level. Listed below are the latest tests approved by the Food and Drug Administration as waived tests under CLIA. The Current Procedural Terminology (CPT) codes for the following new tests must have the modifier QW to be recognized as a waived test. However, the tests mentioned on the first page of the attached list (i.e., CPT codes: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be recognized as a waived test. To read the transmittal in whole go to

5 Third Quarter 2009 Page 5 Medicare Travel Allowance Fees for Collections of Specimens Transmittal 1790 dated August 7, 2009 This Change Request (CR) is to revise the payment of travel allowances, either on a per mileage basis (P9603) or on a flat rate basis (P9604) for CY Medicare, under Part B, covers a specimen collection fee and travel allowance for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient under Section 1833(h)(3) of the Act and payment is made based on the clinical laboratory fee schedule. Travel Allowance The travel codes allow for payment either on a per mileage basis (P9603) or on a flat rate per trip basis (P9604). Payment of the travel allowance is made only if a specimen collection fee is also payable. The travel allowance is intended to cover the estimated travel costs of collecting a specimen including the laboratory technician s salary and travel expenses. Contractor discretion allows the contractor to choose either a mileage basis or a flat rate, and how to set each type of allowance. Because of audit evidence that some laboratories abused the per mileage fee basis by claiming travel mileage in excess of the minimum distance necessary for a laboratory technician to travel for specimen collection, many contractors established local policy to pay based on a flat rate basis only. Under either method, when one trip is made for multiple specimen collections (e.g., at a nursing home), the travel payment component is prorated based on the number of specimens collected on that trip, for both Medicare and non-medicare patients, either at the time the claim is submitted by the laboratory or when the flat rate is set by the contractor. Per Mile Travel Allowance (P9603) The per mile travel allowance is to be used in situations where the average trip to the patients homes is longer than 20 miles round trip, and is to be prorated in situations where specimens are drawn from non-medicare patients in the same trip. The allowance per mile was computed using the Federal mileage rate of $0.55 per mile plus an additional $0.45 per mile to cover the technician s time and travel costs. Contractors have the option of establishing a higher per mile rate in excess of the minimum $1.00 per mile if local conditions warrant it. The minimum mileage rate will be reviewed and updated in conjunction with the Clinical Laboratory Fee Schedule (CLFS) as needed. At no time will the laboratory be allowed to bill for more miles than are reasonable or for miles that are not actually traveled by the laboratory technician. Per Flat-Rate Trip Basis Travel Allowance (P9604) The per flat-rate trip basis travel allowance is $ The standard mileage rate for business used here is based on a study of the fixed and variable costs of operating an automobile. This study is conducted on an annual basis for the Internal Revenue Service (IRS). To read the transmittal in whole go to:

6 Third Quarter 2009 Page 6 Diabetes Self-Management Training (DSMT) Certified Diabetic Educator Transmittal 109 dated August 7, 2009 The purpose of transmittal 109 is to allow for an exception for rural areas and to recognize an approved national accreditation organization. In a rural area, an individual who is qualified as a registered dietitian and as a certified diabetic educator that is currently certified by an organization approved by CMS may furnish training and is deemed to meet the multidisciplinary team requirement. The Medicare Program: Application by the American Association of Diabetes Educators (AADE) for Recognition as a National Accreditation Organization for Accrediting Entities to Furnish Outpatient Diabetes Self-Management Training (DSMT) final rule was released. It was published in the Federal Register on February 27, 2009, Volume 74, effective March 30, 2009; CMS determined that the AADE is recognized as an approved national accreditation organization to furnish DSMT. Providers/suppliers of DSMT services may submit requests for accreditation and Medicare contractors shall recognize the AADE. To read the transmittal in whole go to Sleep Testing for Obstructive Sleep Apnea (OSA) transmittal 103 dated July 10, 2009 Effective for claims with dates of service on and after March 3, 2009, Medicare will allow for the coverage of the following: 1. Type I PSG is covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed attended in a sleep lab facility. 2. Type II or a Type III sleep testing device is covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility. 3. Type IV sleep testing device measuring three or more channels, one of which is airflow, is covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility. 4. Sleep testing device measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone is covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility. NOTE: All current claims processing and associated coding remain unchanged. Consult previous Transmittal 96, Change Request 6048, dated October 15, 2008, for detailed information in this regard. To view transmittal 103 in full go to:

7 Third Quarter 2009 Page 7 Fractional Mileage Amounts Submitted on Ambulance Claims Transmittal 1787 dated July 31, 2009 Effective for claims with dates of service on and after January 1, 2010, ambulance suppliers must report fractional mileage units rounded to the nearest tenth of a mile for all claims for mileage totaling up to, but not including, 100 covered miles. Suppliers must submit fractional mileage using a decimal in the appropriate place (e.g., 99.9). Contractors shall truncate mileage units with fractional amounts reported to greater than one decimal place; e.g., will become 99.9 after truncating the hundredths place. For trips totaling 100 covered miles and greater, suppliers shall continue to report mileage rounded to the nearest whole number mile (e.g., 999). Contractors shall truncate mileage units totaling 100 and greater that are reported with fractional mileage; e.g., will become 100 after truncating the decimal places. For mileage totaling less than 1 mile, suppliers must include a 0 prior to the decimal point (e.g., 0.9). Note: This policy applies only to ambulances services billed on a CMS-1500 paper claim or ANSI X12N 837P electronic claim. Mileage is reported in Item 24G of the CMS-1500 claim form or the corresponding loop and segment of the ANSI X12N 837P. This policy does not apply to hospital-based ambulance services. For ambulance mileage HCPCS only, Contractors shall automatically default 0.1 unit when the total mileage units are missing in Item 24G. To read the transmittal in whole go to: Billing for an Ambulance Transport with More Than One Patient Onboard Transmittal 1821 dated September 25, 2009 The Centers for Medicare and Medicaid Services (CMS) issued Transmittal B , Change Request (CR) 1945, Payment Policy When More Than One Patient is Onboard an Ambulance on September 27, 2002, and Transmittal A , CR 2186 Multiple Patient Ambulance Transport on October 25, These CRs included the payment policy as well as claims processing instructions for ambulance service claims submitted for trips with more than one patient onboard. However, the claims processing instructions were never added to the Ambulance chapter of the Medicare Claims Processing Manual (Publication , Chapter 15). Transmittal 1821 indicates the update to the Claims Processing Manual. Ambulance suppliers submitting a claim using the CMS-1500 Form, or the electronic equivalent ANSI X12N 837, for an ambulance transport with more than one Medicare beneficiary onboard must use the GM modifier ( Multiple Patient on One Ambulance Trip ) for each service line item. In addition, suppliers are required to submit to B/MACs / Carriers documentation to specify the particulars of a multiple patient transport. The documentation must include the total number of patients transported in the vehicle at the same time and the health insurance claim (HIC) numbers for each Medicare beneficiary. B/MACs / Carriers shall calculate payment amounts based on policy instructions found in P u b ,Medic ar e Benefit Policy Manual, Chapter 10 Ambulance Services, Section Multiple Patient Ambulance Transport. To read the transmittal in whole go to

8 Third Quarter 2009 Newsletter Prepared By: 155 Franklin Road, Suite 100 Brentwood, TN Phone: (800) Fax: (615) Page 8 Since 1989 HMI Corporation, a Healthcare Management Company, 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, and on-site education/training of clinical staff and physicians. Our fifteen-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. Q & A Corner HMI would like to express our gratitude to those serving our country here and abroad. Thank you! The information contained herein is solely for the purpose of informing you the health care professional of current changes. Every effort has been made to ensure the accuracy of the contents. However, this newsletter does not replace policies or guidelines set by your Medicare FI or replace the ICD-9-CM or CPT/ HCPCS coding manuals. It serves only as a resource. Q : Why does my business office encounter so many edits for EKG (CPT code 93005)? A : CPT code typically receives an edit (due to NCCI) when reported on the same claim as a procedure. There are also local coverage determinations maintained by the MAC/FI requiring a covered diagnosis. Most often the EKG is being performed as a screening exam prior to a patient having an outpatient procedure. In these cases, the hospital should be reporting the applicable ICD-9-CM V code along with any diagnosis to support billing for this service. When the patient does not have a supporting/covered diagnosis, then it is prudent to obtain a signed ABN