how to better utilize medicareaapcperfect.s3.amazonaws.com/a3c7c3fe-6fa1-4d67... · • 100-04...

HOW TO BETTER UTILIZE MEDICARE

RESOURCES FOR PHYSICIAN CODING

Tyler Griffeth MOL, CPC, CPRC

DENIED!

• To Appeal or not to Appeal

Or just make sure its right

in the first place. ☺

Internet Only Manuals (IOMs)

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html

IOMs

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html

IOMs• 100-04 Medicare Claims Processing Manual

• Chapter 12 – Physicians/Nonphysician Practitioners

• Chapter 18 – Preventive and Screening Services

• Chapter 11 – Processing Hospice Claims

• 100-02 Medicare Benefit Policy Manual

• Chapter 15 – Covered Medical and Other Health Services

IOMs – Example 1• RAC Audit

• 99239s (Inpatient Discharge) being denied

Can’t Appeal, Right?



• Documentation shows >30 minutes spent in discharge

https://www.cms.gov/Research-Statistics-Data-

and-Systems/Monitoring-Programs/Medicare-

FFS-Compliance-Programs/Recovery-Audit-

Program/Approved-RAC-Topics-Items/0038-

Visits-to-Patients-in-Swing-Beds.html

IOM Example 1• RAC Audit



• Rural location with swing beds

• What is a swing Bed?

IOMs – Example 1In order to address the shortage of rural SNF beds for Medicare

patients, rural hospitals with fewer than 100 beds may be reimbursed

under Medicare for furnishing post-hospital extended care services to

Medicare beneficiaries. Such a hospital, known as a swing bed facility,

can “swing” its beds between the hospital and SNF levels of care, on

an as needed basis, if it has obtained a swing bed approval from the

Department of Health and Human Services.

-Medicare Benefit Policy Manual; Chapter 8; 10.3

IOMs – Example 1When a hospital is providing extended care services, it will be treated as a SNF for purposes of applying coverage rules. This means that services provided in the swing bed are subject to the same Part A coverage, deductible, coinsurance and physician certification/recertification provisions that are applicable to SNF extended care services. The SNF coverage provisions are set forth in 42 CFR 409 Subpart D and are more fully explained in this chapter. A patient in a swing bed cannot simultaneously receive coverage for both SNF-level services under Part A and inpatient hospital ancillary services under Part B.

-Medicare Benefit Policy Manual; Chapter 8; 10.3

IOMs – Example 1The swing-bed concept allows a hospital to use their beds interchangeably for either acute-care or post-acute care. A “swing-bed” is a change in reimbursement status. The patient swings from receiving acute-care services and reimbursement to receiving skilled nursing (SNF) services and reimbursement…Swing beds do not have to be located in a special section of the hospital. The patient does not have to change locations in the hospital merely because their status changes unless the hospital requires it.

-State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals; Interpretive Guidelines §482.58




• Rural location with swing beds

• Swing-bed patients

• 99239 → 99316

IOMs – Example 2• RAC

• New patient visits denied

IOMs – Example 2A. Definition of New Patient for Selection of E/M Visit Code

Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 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.

-Medicare Claims Processing Manual, Chapter 12, Section 30.6.7

IOMs – Example 2• 100-04 Medicare Claims Processing Manual, Chapter 26, 10.8.2

IOMs – Example 2• Specialty Code to Taxonomy Description

https://data.cms.gov/Medicare-Enrollment/CROSSWALK-MEDICARE-PROVIDER-SUPPLIER-to-HEALTHCARE/j75i-rw8y/data

A group practice is a group of two or more physicians and non-physician practitioners legally organized in a partnership, professional corporation, foundation, not-for-profit corporation, faculty practice plan, or similar association:

• In which each physician who is a member of the group provides substantially the full range of services which the physician routinely provides (including medical care, consultation, diagnosis, or treatment) through the joint use of shared office space, facilities, equipment, and personnel;

• For which substantially all of the services of the physicians who are members of the group are provided through the group and are billed in the name of the group and amounts so received are treated as receipts of the group;

• In which the overhead expenses of and the income from the practice are distributed in accordance with methods previously determined by members of the group; and

• Which meets such other standards as the Secretary may impose by regulation to implement §1877(h)(4) of the Social Security Act. The group practice definition also applies to health care practitioners.

-Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 90.4

IOMs – Example 2

IOMs – Example 2

IOMs – Example 2• RAC

• New patient visits denied

• Seen by provider of same specialty at different location but still same

group

• Rebill as established patient visits

IOMs – Example 3• Inpatient codes denied

• Both providers are have same specialty code

IOMs – Example 3Concurrent care exists where more than one physician renders services more extensive than consultative services during a period of time.

In order to determine whether concurrent physicians’ services are reasonable and necessary, the A/B MAC (B) must decide the following:

1. Whether the patient’s condition warrants the services of more than one physician on an attending (rather than consultative) basis, and

2. Whether the individual services provided by each physician are reasonable and necessary.

-Medicare Benefit Policy Manual, Chapter 15, Section 30.E

IOMs – Example 3While it would not be highly unusual for concurrent care performed by physicians in different specialties (e.g., a surgeon and an internist) or by physicians in different subspecialties of the same specialty (e.g., an allergist and a cardiologist) to be found medically necessary, the need for such care by physicians in the same specialty or subspecialty (e.g., two internists or two cardiologists) would occur infrequently since in most cases both physicians would possess the skills and knowledge necessary to treat the patient. However, circumstances could arise which would necessitate such care. For example, a patient may require the services of two physicians in the same specialty or sub-specialty when one physician has further limited his or her practice to some unusual aspect of that specialty, e.g., tropical medicine.

-Medicare Benefit Policy Manual, Chapter 15, Section 30.E

IOMs – Example 3• Inpatient codes denied

• Both providers are have same specialty code

• Appeal with documentation and rationale to show both services are

“reasonable and necessary”

National Correct Coding Initiative (NCCI)

• The CMS developed the National Correct Coding Initiative (NCCI) to

promote national correct coding methodologies and to control

improper coding leading to inappropriate payment in Part B claims

• The CMS developed its coding policies based on coding conventions

defined in the American Medical Association's CPT Manual, national

and local policies and edits, coding guidelines developed by national

societies, analysis of standard medical and surgical practices, and a

review of current coding practices

NCCI• Manual

• General reference tool that explains the rationale for NCCI edits

• Updated annually

• Procedure to Procedure Coding Edits

• Prevent improper payment when incorrect code combinations are reported

• Updated quarterly

NCCI• Medically Unlikely Edits

• The purpose of the NCCI MUE program is to prevent improper payments when

services are reported with incorrect units of service


• Add-on Code Edits

• Listing of HCPCS and CPT add-on codes with their respective primary codes


NCCI

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf

NCCI

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

NCCI – Manual


NCCI – Manual Archive


NCCI – Manual Archive

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Manual-Archive.html

NCCI – Manual

NCCI – PTP Coding Edits• NCCI PTP edits prevent inappropriate payment of services that

should not be reported together

• Each edit has a column one and column two HCPCS/CPT code

• The column one code is eligible for payment

• The column two code is denied unless a clinically appropriate

NCCI-associated modifier is also reported

NCCI – PTP Coding Edits• CPT codes representing services denied based on NCCI PTP edits

may not be billed to Medicare beneficiaries. Since these denials are

based on incorrect coding rather than medical necessity, the provider

cannot utilize an “Advanced Beneficiary Notice” (ABN) form to seek

payment from a Medicare beneficiary

• Physicians shall not inconvenience beneficiaries nor increase risks to

beneficiaries by performing services on different dates of service to

avoid MUE or NCCI PTP edits

NCCI – PTP Coding Edits


https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html

NCCI – PTP Coding Edits• An NCCI edit is applicable to the time period for which the edit is

effective since the edit is based on coding instructions and practices

in place during the edit’s effective dates

• A change in an NCCI edit is not retroactive and has no bearing on

prior services unless specifically updated with a retroactive effective

date

NCCI – PTP Coding Edits• Modifier Indicator “0” (Not Allowed)

• No modifiers associated with NCCI allowed to be used with this PTP code pair

• Modifier Indicator “1” (Allowed)

• Modifiers associated with NCCI allowed with this PTP code pair when appropriate

• Documentation must support why services appropriate for circumstance (e.g., different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion/injury)

• Modifier Indictor “9” (Not Applicable)

• NCCI edit does not apply to this PTP code pair

• Edit for this PRP code pair was deleted retroactively; used for all code pairs that have a deletion date that is the same as the effective date (this indicator was created so that no blank spaces would be in the indicator field)

Medicare Claims Processing Manual; Chapter 23 - Fee Schedule Administration and Coding Requirements; 20.9 – National Correct Coding Initiative (CCI)

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf

• 73565 (Radiologic examination, knee; standing, anteroposterior)

• 7356???

PTP Coding Edit – Example

For a given radiographic series, the procedure code that most

accurately describes what was performed shall be reported. Because

the number of views necessary to obtain medically useful information

may vary, a complete review of CPT coding options for a given

radiographic session is important to assure accurate coding with the

most comprehensive code describing the services performed rather

than billing multiple codes to describe the service.

-NCCI Manual, Chapter 9


PTP Coding Edit – Example 2• Surgeon Performs a myocutaneous flap (15734) with a free flap breast

reconstruction (19364).

• The service comes back denied.

Too bad

• No

NCCI policy Manual Chapter 3 - 7.

CPT code 15734 (muscle, myocutaneous, or

fasciocutaneous flap, trunk) shall not be reported with

breast reconstruction CPT codes 19357-19364 and

19367-19369 or breast prosthesis CPT codes 19340 and

19342 since a flap, if performed, is included in the

reconstruction or prosthesis procedure.

So – Too bad, Right?

• Maybe, but a 59 modifier Might be appropriate.

• Check the documentation,

• If it fits the definition of the 59 modifier =

• Append and Resubmit.

NCCI – Medically Unlikely Edits (MUE)

• Prevent payment for an inappropriate number/quantity of the same

service on a single day

• An MUE for a HCPCS/CPT code is the maximum number of units of

service (UOS) under most circumstances reportable by the same

provider for the same beneficiary on the same date of service

• Not all HCPCS/CPT codes have MUE values

• Majority of MUEs are made public and posted on the CMS website

NCCI – MUE• Based on HCPCS/CPT code descriptors

• CPT coding instructions

• Anatomic considerations

• Established CMS policies

• Nature of service/procedure

• Clinical judgment

NCCI – MUEConsistent with NCCI guidance, denials resulting from MUEs are not

based on any of the statutory provisions that give liability protection to

beneficiaries under section 1879 of the Social Security Act. Thus, ABN

issuance based on an MUE is NOT appropriate. A provider/ supplier

may not issue an ABN in connection with services denied due to an

MUE and cannot bill the beneficiary for units of service denied based

on an MUE.

-2019 NCCI Manual, Introduction

NCCI – MUE

NCCI – MUE

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html

NCCI – MUE

NCCI – MUE Indicators

• MACs adjudicating an appeal for a claim denial for a HCPCS code

with an MUE with an MAI of “1” or “3” may pay correctly coded and

correctly counted medically necessary UOS in excess of the MUE

value

NCCI – MUE Indicators• An MAI of “1” indicates that the edit is a

• Claim line MUE

• Appropriate use of CPT modifiers (e.g., 59, 76, 77, 91, anatomic)

may be used to report the same HCPCS/CPT code on separate

lines of a claim

• Each line of the claim with that HCPCS/CPT code will be

separately adjudicated against the MUE value for that

HCPCS/CPT code


• DOS MUE

• Absolute date of service edits

• “per day edits based on policy”.

• UOS on the same date of service (DOS) in excess of the MUE value would be considered impossible because it was contrary to statute, regulation or subregulatoryguidance

• Limitations created by anatomical or coding limitations are incorporated in correct coding policy, both in the HIPAA mandated coding descriptors and CMS approved coding guidance as well as specific guidance in CMS and NCCI manuals


• DOS MUE

• “per day edits based on clinical benchmarks”

• Based on criteria (e.g., nature of service, prescribing information) combined with data such that it would be possible but medically highly unlikely that higher values would represent correctly reported medically necessary services

• If contractors have evidence (e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and were medically necessary, the contractor may bypass the MUE for a HCPCS code with an MAI of “3” during claim processing, reopening or redetermination, or in response to effectuation instructions from a reconsideration or higher level appeal

NCCI – MUEBilling Units in Excess of MUE

• Bill one line with the revenue code, HCPC/CPT, date of service, no modifier and correct number of unit(s) for MUE

• Bill one subsequent line with units exceeding MUE value and any appropriate modifier OR

• Split remaining units and bill all lines individually with appropriate modifier

(MAI of 2 or 3 will deny even with modifier)

NCCI – MUE Example• Denied 77300 x14 (Basic radiation dosimetry calculation) due to

exceeding MUE

NCCI – MUE Example• An MAI of “3” indicates that the edit is a

• DOS MUE

• “per day edits based on clinical benchmarks”

• Based on criteria (e.g., nature of service, prescribing information) combined with data such that it would be possible but medically highly unlikely that higher values would represent correctly reported medically necessary services

• If contractors have evidence (e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and were medically necessary, the contractor may bypass the MUE for a HCPCS code with an MAI of “3” during claim processing, reopening or redetermination, or in response to effectuation instructions from a reconsideration or higher level appeal

NCCI – MUE Example• Denied 77300 x14 (Basic radiation dosimetry calculation) due to

exceeding MUE

• Documentation shows multiple neoplasms were being treated,

requiring 7 dose calculations for each

• Appeal with documentation and rationale

NCCI – MUE Example 2• Code 44125

• Enterectomy, resection of small intestine; with enterostomy

• MUE – 1

• MIA – 2

• NO APPEAL

NCCI – PTP and MUE Updates Only

NCCI – PTP and MUE Updates Only

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes.html

NCCI – Add-On Code Edits

NCCI – Add-On Code Edits

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Add-On-Code-Edits.html

NCCI – Add-On Code Edits• CMS has divided the add-on codes into three groups to distinguish the payment policy for each group.

• Type I - A Type I add-on code has a limited number of identifiable primary procedure codes. The CR lists the Type I add-on codes with their

acceptable primary procedure codes. A Type I add-on code, with one exception, is eligible for payment if one of the listed primary

procedure codes is also eligible for payment to the same practitioner for the same patient on the same date of service. Claims processing

contractors must adopt edits to assure that Type I add-on codes are never paid unless a listed primary procedure code is also paid.

• Type II - A Type II add-on code does not have a specific list of primary procedure codes. The CR lists the Type II add-on codes without any primary procedure codes. Claims processing contractors are encouraged to develop their own lists of primary procedure codes for this type of add-on codes. Like the Type I add-on codes, a Type II add-on code is eligible for payment if an acceptable primary procedure code as determined by the claims processing contractor is also eligible for payment to the same practitioner for the same patient on the same date of service.

• Type III - A Type III add-on code has some, but not all, specific primary procedure codes identified in the CPT Manual. The CR lists the Type III add-on codes with the primary procedure codes that are specifically identifiable. However, claims processing contractors are advised that these lists are not exclusive and there are other acceptable primary procedure codes for add-on codes in this Type. Claims processing contractors are encouraged to develop their own lists of additional primary procedure codes for this group of add-on codes. Like the Type I add-on codes, a Type III add-on code is eligible for payment if an acceptable primary procedure code as determined by the claims processing contractor is also eligible for payment to the same practitioner for the same patient on the same date of service

Medicare Physician Fee Schedule

https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/

Medicare Physician Fee Schedule

Medicare Physician Fee Schedule -

Example• S2068 Rant

• Rant Complete

Thank you

Local/National Coverage Determinations (LCDs/NCDs)

https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?FriendlyError=NoContractorIDVersion,InvalidDocumentType#ResultsAnchor

LCDs/NCDs• Coverage guidance

• Supported diagnosis codes

LCD – Example 1• Denial 77301 (Intensity Modulated Radiation Therapy)

• Diagnosis code (C79.51 - Secondary malignant neoplasm of bone)

not listed on LCD

• Secondary malignant neoplasm of spinal column

LCD – Example 1IMRT is considered reasonable and necessary in instances where sparing the surrounding normal tissue is essential and the patient has at least one of the following conditions met:

1. Important dose limiting structures adjacent to, but outside the PTV, are sufficiently close and require IMRT to assure safety and morbidity reduction.

2. An immediately adjacent volume has been irradiated and abutting portals must be established with high precision.

3. Gross Tumor Volume (GTV) margins are concave or convex and in close proximity to critical structures that must be protected to avoid unacceptable morbidity.

4. Only IMRT techniques would decrease the probability of grade 2 or grade 3 radiation toxicity as compared to conventional radiation in greater than 15% of radiated similar cases.

-LCD: Intensity Modulated Radiation Therapy (L34080)

LCD – Example 1• Denial 77301 (Intensity Modulated Radiation Therapy)

• Diagnosis code (C79.51 - Secondary malignant neoplasm of bone)

not listed on LCD

• Secondary malignant neoplasm of spinal column

• Appeal with documentation and explanation citing LCD coverage

indications

LCD – Example 2Indications for SRS/SBRT (for Cranial Lesions only):

1. Primary central nervous system malignancies, generally used as a boost or salvage therapy for lesions < 5 cm.2. Primary and secondary tumors involving the brain or spine parenchyma, meninges/dura, or immediately adjacent bony structures.3. Benign brain tumors and spinal tumors such as meningiomas, acoustic neuromas, other schwannomas, pituitary adenomas, pineocytomas, craniopharyngiomas, glomus tumors, hemangioblastomas.4. Cranial arteriovenous malformations, cavernous malformations, and hemangiomas5. Other cranial non-neoplastic conditions such as trigeminal neuralgia and select cases of medically refractory epilepsy. As a boost treatment for larger cranial or spinal lesions that have been treated initially with external beam radiation therapy or surgery (e.g. sarcomas, chondrosarcomas, chordomas, and nasopharyngeal or paranasal sinus malignancies).6. Metastatic brain or spine lesions, with stable systemic disease, Karnofsky Performance Status 40 or greater (or expected to return to 70 or greater with treatment), and other wise reasonable survival expectations, OR an Eastern Cooperative Oncology Group (ECOG) Performance Status of 3 or less (or expected to return to 2 or less with treatment).7. Relapse in a previously irradiated cranial or spinal field where the additional stereotactic precision is required to avoid unacceptable vital tissue radiation.8. Unilateral thalamotomy using stereotactic radiosurgery may be used to treat limb tremor in Essential Tremor that is refractory to medical management using at least two drugs but is not currently recommended by the Guidelines of the American Academy of Neurology.

-LCD: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (L34151)

Documentation Requirement Lookup ServiceProviders will be able to discover Medicare FFS prior authorization and documentation requirements:

• At the time of service

• Within their electronic health record (EHR) or integrated practice management system

For example, providers will be able to answer questions such as:

• Is prior authorization required by Medicare FFS for the item or service for which I’m about to refer my patient?

• Does Medicare FFS have documentation requirements for the item I’m about to order for my patient?

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/LookupServiceInitiative.html

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/LookupServiceInitiative.html

Tyler Griffeth, [email protected]

how to better utilize medicareaapcperfect.s3.amazonaws.com/a3c7c3fe-6fa1-4d67... · • 100-04...

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