| QUESTION Aug 2010: Our new business manager is advising that we should not bill the 99211 code when a patient comes in for chemo unless the patient has a problem which would identify it as a separate service. Our commercial payers are paying but our billing manager is stating we should not be billing it. When a patient comes in to the office for a chemo- therapy visit and they do not see the doctor, our nurses complete an assessment and use clinical judgment to decide if the patient is able to receive their therapy. An full assess- ment is completed and documented…questioning any problems since last visit. We address appetite, nausea, vomiting, pain, fatigue, bowel habits, fever, etc. Our new manager sites the following:
Billing 99211 in addition to chemotherapy administration codes (96400-96549). The administration of chemotherapy does not automatically justify billing a 99211 visit. The documentation must support that an E/M service was provided. The chemo administration code includes such things as the insertion of a catheter, set-up of the IV, administration of the medication, monitoring of adverse reactions during treatment. However, should a problem arise that requires a significant, separately identifiable E/M service, then the appropriate level E/M code should be reported in addition to the chemo. The following clinical example would support billing 99211 with modifier 25: The patient was questioned regarding any problems/side effects since the last visit and the notes indicate the patient is experiencing significant nausea, and weight loss has occurred. This is communicated to the physician and some form of patient E/M occurred (e.g., prescription for medication, patient education, diet change, etc.). I would appreciate any thoughts you have! I understand that Medicare is saying that this code is bundled in the chemo admin codes but if commercial payers are not questioning, can we continue to bill? ANSWER: I mostly agree with your new business manager. According to the AMA CPT guidelines;
service code should be reported using modifier 25 in addition to 96360 – 96549. For same day E/M service, a different diagnosis is not required.” The confusion lies in the definition of “separately identifiable”. Many payers feel that a basic evaluation is assumed and reimbursed with the RVU’s included in the reimbursement of the administration code. Therefore, the evaluation directly related to the chemotherapy treatment would not be considered separately identifiable. However, if a patient presents with a problem - like a cold or flu - unrelated to the chemotherapy and is evaluated, then it would be appropriate to use the 25 modifier and identify the service as a separately identifiable service. Medicare CERT and many other payer audits are being conducted related to proper utilization of modifier 25 so make sure your utilization and documentation is appropriate! **************************************************************** QUESTION Aug 2010: We have been told that the generic version of Oxaliplatin is off the market and no longer available. Is this true? What happens now to our Medicare pricing since the generic pricing was included in the ASP? ANSWER: Sanofi-Aventis signed settlement agreements in April, 2010 with Teva, APP, Sandoz, Hospira, and Sun Pharmaceuticals requiring the companies to stop selling unauthorized generic oxaliplatin products from June 30, 2010 to August 9, 2012. Additional information is available in the Sanofi-Aventis press release. ASP pricing methodology uses quarterly drug pricing data submitted to the CMS by drug manufacturers quarterly. During the next quarter CMS analyzes the data and then release the updated ASP the following quarter so pricing changes take an average 6 months. During this time period many changes occur, some drugs costs are higher, some lower, some drugs entering the market while others are leaving. When generic drugs enter the market at a lower cost than the brand, CMS does not change the ASP until the pricing data is received. In the case of oxaliplatin, the generic drug is removed from the market and it is most likely that the pricing will not be reflected in the ASP until the new pricing data is received and analyzed. We have been told that there is currently a 6 to 7 month supply of the generic oxaliplatin available at this time. Since this product was sold to the US market prior to the cease order effective June 30th, there will no longer be sales of the generic oxaliplatin and therefore sales will be reported to CMS over the upcoming months. This should allow practices to continue to purchase generic oxaliplatin until the end of the year which in turn should allow enough time for the pricing changes to catch up and keep the practices whole. **************************************************************** QUESTION Aug 2010: Is anyone billing for ARA-C (cytarabine) intrathecal by reservoir administered by Doctor? Not sure what code to use. ANSWER: Ommaya reservoir is a device that is surgically inserted under the scalp for direct injection of chemotherapy into the spinal fluid. When intrathecal chemotherapy is needed, an Ommaya allows drugs to be administered into the reservoir, rather than through the back during a spinal tap. Administering chemotherapy through an Ommaya is a sterile procedure, performed by a physician or trained and supervised assistant. Use 96542 (Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents) when administering chemotherapy via the Ommaya reservoir. The chemotherapy agent administered should be billed using the appropriate J code. If a significant, separately identifiable evaluation and management service is performed, the appropriate E/M service code should also be reported. Code 96450 should be used when a spinal tap is required with chemotherapy administration. This code is defined in CPT 2002 as ?Chemotherapy administration, into CNS (e.g., intrathecal), requiring and including spinal puncture.? Note that the spinal tap is included with 96450. It is not appropriate to bill separately for the spinal tap. Again, the chemotherapy agent should be billed using the appropriate J code, as well as E/M services if provided. **************************************************************** QUESTION July 2010: I had a claim sampled for CERT. I submitted all of the requested documentation months ago, but have not received a response from AdvanceMed, the CERT review contractor, or Palmetto GBA. Is it safe to assume that the review did not result in an error? ANSWER: Probably yes. If four or more months have passed since your response, you are certain that you submitted all of the requested documentation and you have not heard back from Palmetto GBA, then it is highly likely that the CERT review resulted in an approval. The only time you are notified of the outcome of the CERT review is when an adverse error determination has been made, e.g.,. insufficient documentation, incorrect coding, medically unnecessary service, no documentation, etc. If an error was identified, Palmetto GBA would have adjusted the claim and contacted you to request a refund of any overpayments made. In general, no news is good news. **************************************************************** QUESTION July 2010: If the ordering/referring provider information is not on the claim when will Medicare begin to reject claims? ANSWER: Phase 2 of Change Request 6417 had been delayed until Jan. 3, 2011 to give physicians and nonphysician practitioners who order items or services for Medicare beneficiaries or who refer Medicare beneficiaries to other Medicare providers or suppliers sufficient time to enroll in Medicare or take the action necessary to establish a current enrollment record in Medicare. However, physicians and “eligible” providers received a jolt in the May 5, 2010 Federal Register as the date for enrollment in PECOS was moved up (pending the comment period and any changes resulting from the comment period) six months for providers that order or supply durable medical equipment (DME) for Medicare patients. Instead of the January 3, 2011 date previously announced by CMS, the Patient Protection and Affordable Care Act (Affordable Care Act or PPACA) has provisions to move the go-date to July 6, 2010. Learn more about PECOS, the enrollment changes and impact at the AMA site: http://www.ama-assn.org/amednews/2010/06/14/gvl10614.htm Here is the link to read about the change on Federal Register: http://edocket.access.gpo.gov/2010/2010-10505.htm **************************************************************** QUESTION July 2010: A Medicare patient was receiving treatment in our office. In the middle of the treatment the supervising physician left and was replaced by another doctor in our group who became the supervising physician. Who should we bill under, there are two supervising physicians! ANSWER: Choose the physician that was present during the majority of the service. It states in section "F-b" in the National Policy for Incident To: "In the case where a long service requires more than one supervisor, the physician who had the responsibility for the major part of the service should be identified on the claim." **************************************************************** QUESTION (June 2010): Our office utilized a drug off label and the NCCN Compendia had the drug and indication listed. I billed the claim to Medicare but received a denial. I thought if the indication was included in NCCN Compendia, it would be covered! Help! ANSWER: Believe it or not, Medicare Carriers/MAC’s do not automatically load NCCN compendia into their LCD's nor do they have access to the compendia. Most will, upon request, add the indications if a copy of the NCCN compendia listing is sent to them with the request. In the meantime, your claim should still be covered but you will have to appeal. Make sure you mention and supply a copy of the NCCN compendia listing with your appeal. You should also reference the Medicare guidelines below: Policy: CMS is recognizing the following as authoritative compendia and listing them in Pub. 100-02 of the Medicare Benefit Policy Manual, chapter 15, section 50.4.5 for use in the determination of a “medically-accepted indication” of drugs and biologicals used off-label in an anti-cancer chemotherapeutic regimen: •American Hospital Formulary Service-Drug Information (AHFS-DI) •NCCN Drugs and Biologics Compendium •Thomson Micromedex DrugDex •Clinical Pharmacology Contractors shall recognize medically accepted indications as those that: •are favorably listed in one or more of the compendia listed above, or, •the contractor determines from a review of the peer-reviewed literature as described above that it is a medically accepted indication, unless CMS has determined that the use is not medically accepted, or any of the listed compendia list the use as not medically accepted, or words to that effect. CMS is aware that the listed compendia employ various rating and recommendation systems that may not be readily cross- walked from compendium to compendium. In general, a use is identified by a compendium as medically accepted if the: 1.indication is a Category 1 or 2A in NCCN, or Class I, Class IIa, or Class IIb in DrugDex; or, 2.narrative text in AHFS or Clinical Pharmacology is supportive. A use is not medically accepted by a compendium if the: 1. indication is a Category 3 in NCCN or a Class III in DrugDex; or, 2. narrative text in AHFS or Clinical Pharmacology is “not supportive.” **************************************************************** QUESTION (June 2010): Our practice used a portion of a multidose vial on a patient but the remainder was only good for a month and we had to throw it away. Is it appropriate to bill Medicare for the whole vial? If not, what else can we do? ANSWER: It would not be appropriate to bill Medicare for the whole vial. Medicare only reimburses waste from a single dose vial. You really do not have much of an option when a portion of a multidose vial is wasted. Billing the insurance or the patient would not be appropriate. **************************************************************** QUESTION (June 2010): Is there a requirement that our times of infusion be documented as START and STOP? Our nurses document the total time of the administration but not the actual start and stop times. ANSWER: I was not able to locate any document that states that the times must be documented using a start and stop time. Since infusions are billed using time, it is clear that the total time of each infusion must be within the medical record. At the same time, without start and stop times it is difficult to prove that administrations were not concurrent. Charting with start and stop times would certainly make it easier to determine timing of each procedure. I believe from an auditing standpoint it would be better to document start and stop times. **************************************************************** QUESTION (May 2010): Our physician sometimes gives treatments for other providers, not in our group. That physician sends over an order and we give the treatment. Our physician does not sign the order. Is this a problem? ANSWER: It is clear that the services MUST be ordered and signed off by the physician providing the care. **************************************************************** QUESTION (May 2010): I thought Medicare was always primary, how do I know if Medicare is primary or secondary? ANSWER: In most cases, Medicare is primary. Some of the most common situations where Medicare can pay secondary are: -The individual or his/her spouse is currently employed/working and covered under an employer group health plan as a result of current employment. The company has 20 or more employees or participates in a multiple- employer or multi-employer group health plan where at least one employer has 20 or more employees. -Individual in question is entitled to Medicare as a result of a disability, the company has 100 or more employees, or participates in a multi-employer/multiple-employer group health plan where one employer has 100 or more employees. -The individual in question is Medicare entitled due to end-stage renal disease. Medicare is the secondary payer to a group health plan until a 30-month coordination period has ended. -For further explanation on how Medicare pays with other types of insurance, please read: Medicare Coordination of Benefits, Welcome to the Medicare Secondary Payer and You page on http://www.cms.hhs.gov/COBGeneralInformation/. **************************************************************** QUESTION (May 2010): Our physician, in his dictated note said, "Begin the patient on Neulasta". Can this be considered the order? ANSWER: This does not meet the requirements of an order as the dose and route of administration are not included. BCBSM during their POIT audits have been taking back Neulasta payments and the reimbursement for the injection because of this exact issue. Make sure your order meets all the requirements! *********************************************************************** QUESTION (May 2010): If the physician personally writes "Decadron 12 mg" on the Infusion Note, is that considered an "order"? ANSWER: No. Elements of an order: • Medication •Dose •Route •Frequency •Length of treatment •Date •Physician signature *********************************************************************** QUESTION (April 2010): Can a provider who furnished an E/M service that could be described by a CPT consultation code to a Medicare beneficiary bill the beneficiary for his or her charge for the service after providing an ABN? ANSWER: No, an ABN cannot be employed in these circumstances, because ABNs are applicable only where denial of payment is anticipated on grounds of the medical necessity requirement under section 1862(a)(1)(A) of the Social Security Act. E/M services previously reported using CPT consultation codes may be medically reasonable and necessary. CPT consultation codes 99241-99245 and 99251-99255 are now assigned status indicator “I”, which means that these codes are not valid for Medicare purposes, and explicitly provides that “Medicare uses another code for the reporting of, and payment for these services.” *********************************************************************** QUESTION (April 2010): Where do I find the E & M guidelines? ANSWER: The E/M documentation guidelines are available on the CMS website at: http://www.cms.hhs. gov/MLNEdWebGuide/25_EMDOC.asp. *********************************************************************** QUESTION (April 2010): Why does my remittance statement have a late filing charge? ANSWER: Section 1848(g) (4) of the Social Security Act requires that physicians and suppliers complete and submit Part B claims for medical services (furnished on or after September 1, 1990) within 12 months of the service date. Only assigned claims submitted more than 12 months after the service date will be subject to a 10 percent reduction of the amount that would otherwise have been paid. This is referenced on the CMS Web site at http://www.cms.hhs.gov/Manuals/IOM/list.asp publication 100-4, Chapter 1, Section 70.8.8. *********************************************************************** QUESTION (April 2010): If a Medicare patient of Dr A gets chemo and he is not here, only a NP is present, the claim gets billed as ordering A, supervising A, as long as he is in town and available, correct? ANSWER: Incorrect. To qualify for "incident to" the supervising physician MUST be in the suite and readily available. This claim would need to be billed under the NP’s NPI number. The services will be reimbursed at 85% of the physician fee schedule, but drugs will be reimbursed at ASP plus 6% as usual. *********************************************************************** QUESTION (April 2010): When a medical assistant (MA) takes and records the vital signs in the chart of a flow sheet, does the physician need to include the information in his/her note or reference them in his note in order to receive credit under the “constitutional section” for E/M coding? ANSWER: Yes, the vital signs need to be referenced. If the MA wrote them in the flow chart, it would not be apparent the physician saw the vitals unless the physician actually referenced them or re-dictated them in his/her note. In a physician’s handwritten note for a visit, the MA will usually write the vitals at the beginning. In that case, it would be a fair assumption that the physician saw and was aware of the vitals and agreed with the findings. In the case of a dictated note, it is assumed that the physician saw the vitals taken by the MA before he/she dictated them. In both of those scenarios, as long as it could be easily inferred from the physician’s notes that the physician was aware of the vitals, nothing further would be necessary. *********************************************************************** QUESTION (Mar 2010): My question is this, when billing J0885 or J0881 we use EA or EC modifiers for Medicare. EA is used when the HGB level is 10. and less and the HCT level is 30. and less. EC is used when the HGB level is 10.1 and above and the HCT level is 30.1 and above. Is this correct? ANSWER: Deciding which modifier to append is related to the patient's diagnosis, not directly to the HGB or HCT; Effective January 1, 2008, all non-ESRD ESA claims billing HCPCS J0881 and J0885 must begin reporting one (and only one) of the following three modifiers on the same line as the ESA HCPCS: •EA: ESA, anemia, chemo-induced; •EB: ESA, anemia, radio-induced; or •EC: ESA, anemia, non-chemo/radio So if your patient has anemia because they are getting chemotherapy, the EA would apply. If your patient is not on chemo but getting the ESA for a diagnosis that is covered within the NCD, then the EC would apply. There are many rules related to ESA’s and lab values, please review the documents below for more information. Here is the link to the Medlearn Matters Document: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5699.pdf *********************************************************************** QUESTION (Mar 2010): We are interested in participating in Medicare’s E-prescribing and I have a couple of questions. First, do you know where I can find a system? Also, is it true that we only have to report 25 times to qualify for a 2% bonus? How long do we have to report, is it 6 months or till the end of the year? And last question, do we have to do this at some point, will it be a Medicare requirement? ANSWER: You asked 4 questions and I have provided the answers below: 1. Where can I find a system? Here is a link to the AMA site where you will find many systems that are available: https://eprescribing.ama-assn.org/ePrescribing/sysfinder/vendors/view.do A free system that many oncology offices are using can be found at: https://www.oncologyerx.com/default.aspx 2. Is it true we only have to report 25 times to qualify for a 2% bonus? Yes. To be considered a successful electronic prescriber for the 2010 eRx Incentive Program and potentially qualify to earn a 2.0% incentive payment for the 2010 eRx Incentive Program, an individual EP must report the eRx measure for at least 25 unique electronic prescribing events in which the measure is reportable during 2010. (Note – criteria is different if participating as a group – see the CMS site for information related to group reporting) 3. How long do we have to report? The reporting period for the E-Prescribing Incentive Program for 2010 will be the entire calendar year, and incentives will be paid based on the covered professional services furnished by an eligible professional during the reporting year. 4. Do we have to participate, will it be a Medicare requirement? Participation is voluntary, however, beginning in 2012, Medicare will impose penalties on Eligible Professionals who are not successful e-prescribers. Following the distribution of 2010 incentive payments, CMS will, as required by MIPPA, to post on its Web site the names of individual EPs and group practices that are successful e-prescribers for the 2010 E-Prescribing Incentive Program. ------------------------------------------------------------------------------------ For more information visit the CMS site: http://www.cms.hhs.gov/ERxIncentive/01_Overview.asp#TopOfPage 2010 E-Prescribing Fact Sheet: http://www.cms.hhs.gov/apps/media/press/factsheet.asp? Counter=3541&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&k eywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date *********************************************************************** QUESTION (Feb 2010): I found a CPT code for drawing blood from a mediport, 36591. I was wondering if Medicare will reimburse for this code? I can't find anything in the CCI edits that say they won't pay this code. Will they? ANSWER: Actually it is not in CCI, for both CPT 36591 and 36592 are listed by the Centers for Medicare & Medicaid Services (CMS) in the 2009 Medicare Physician Fee Schedule Database as "T" status. By CMS national requirements, "T" status codes are "only paid when there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the service(s) for which payment is made." *********************************************************************** QUESTION (Feb 2010): What happens when a Medicare Advantage (MA) patient elects Hospice Coverage? ANSWER: According to the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Chapter 11, Section 40.2.2, when a Medicare Advantage (MA) patient elects hospice coverage, all services come back to Medicare Fee-For-Service (FFS). This is true whether the services are related or unrelated to the hospice condition. If the patient discontinues hospice in the middle of a month, Medicare FFS keeps the patient until the first of the following month when the patient would go back under MA. All of the normal hospice processing instructions apply. See CMS IOM Publication 100-04, Chapter 11, Section 40.1.3. *********************************************************************** QUESTION (Feb 2010): I see there are codes for anti-coagulation management in the 2010 AMA CPT, codes 99363 and 99364. Will Medicare reimburse for these codes when we make Coumadin decisions on a patient that is home bound and the visiting nurse calls us? What about Care Plan Oversight codes? ANSWER: Even though the CPT includes very clear instructions on how to use these codes, Medicare has chosen to bundle CPT codes 99363 and 99364 as part of a physician's evaluation and management service. See article below: Anticoagulation Management: CPT Code Usage Anticoagulation management services are inherent in the services captured by the E/M codes for management of the underlying condition for which the anticoagulation is medically necessary. This is the same as for any other medication used in disease management. CPT code 99211 may not be routinely submitted for monitoring anticoagulation management. Rather, any E/M service submitted, including CPT code 99211 must be medically necessary and supported by the extent of the history, exam and medical decision making documented for the visit. The following are examples of when CPT 99211 may not be submitted for Anticoagulation Management (this list is not all inclusive): -When the in-person encounter with the patient was only for the diagnostic test -For telephone care (this includes instructions on changing dose, assessment and/or education) -When the only documentation would be vital signs, the patient's current and future dose of anticoagulant, and when lab work is to be reported -When direct physician supervision requirements are not met or were not provided by the physician treating the patient's medical problem requiring anticoagulant therapy -For repetitive education that does not serve the medical needs of the individual patient CMS Web Site References: Incident to Guidelines and definition of ancillary/auxiliary staff: Pub. 100-02, chapter 15, section 60 (PDF, 1.2 MB) Evaluation and Management Documentation Guidelines --------------- As to Medicare Coverage of Care Plan Oversight - this comes from the CMS Web site: Care Plan Oversight Services The Medicare Claims Policy Manual contains requirements for coverage. CPO is the physician supervision of patients under the care of home health agencies or hospices that require complex or multidisciplinary care modalities involving: • Regular physician development and/or revision of care plans; • Review of subsequent reports of patient status; • Review of related laboratory and other studies; • Communication with other health professionals not employed in the same practice who are involved in the patient's care; • Integration of new information into the medical treatment plan; and adjustment of medical therapy. --------------- It is a time based code, so on an audit CMS would expect to see "time" noted. Keep in mind that 30 minutes is for a calendar month. If the patient is under a home health agency, that agency should also be sending the physician a form for direction and approval. Review of that treatment plan should also be counted towards that 30 minutes in a calendar month...However, Medicare just does not make separate payment for the management of coumadin. *********************************************************************** QUESTION (Jan 2010): We are an outpatient hospital billing oncology. We were wondering if there is a listing of the pass through drugs for 2010? ANSWER: Yes. They can be found in the Federal Register, Vol 74, No. 223, which was posted on November 20th. Click on the link I have provided and review pages 60470-60471. http://edocket.access.gpo.gov/2009/pdf/E9-26499.pdf *********************************************************************** QUESTION (Jan 2010): Can you confirm the use of Modifier AI? A consultant is telling us that we are to use that modifier if we see a patient in consultation and use the Initial Code. Is this true? ANSWER: No. The ONLY time you will use Modifier AI is when YOU admit the patient. Modifier “-AI,” defined as “Principal Physician of Record,” shall be used by the admitting or attending physician who oversees the patient’s care, as distinct from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier “-AI” in addition to the initial visit code. *********************************************************************** QUESTION (Jan 2010): I am currently using a NOC code when I bill N-Plate. I see that the new HCPCS code was released. I am worried if I use the new code right away I will get a rejection. Do I have to use the new code right away? ANSWER: For services after January 1, 2010, you should utilize the new J-code for NPlate, J2796. If you receive a rejection because the payer does not recognize the code, please contact reimbursement@wvos.info and we will contact the payer to alert them of the problem and help status your claim. *********************************************************************** QUESTION (Jan 2010): We have a few patients that have Medicare secondary and a private insurance as primary. Since Medicare no longer accepts the consultation codes do we have to bill the Initial code for these patients even though the private payer will still pay for the consult codes (and they pay higher by the way!)? ANSWER: Most Carriers/MACS have confirmed that they will allow offices to change the consult code to the most appropriate E & M service applicable. See example below: •When Medicare is primary or secondary:
Medicare •Please check with other payers to see if they have changed any policies relating to consultations •Providers may bill primary payers using the consultation codes, but would need to re-code the service to the appropriate E&M visit code to bill Medicare as secondary •Alternatively, providers may consider billing the appropriate E&M visit code to the primary in order to facilitate the MSP payment *********************************************************************** QUESTION (Jan 2010): Did CMS make adjustments to its proposal in addition to the decision to phase-in the changes over four years? ANSWER: Yes. While these adjustments have a relatively small impact considering the magnitude of the updates to the PE/hr figures, they can have a significant impact on the RVUs assigned to specific services and, thus, on specific specialties. The CMS modification related specifically to hematology/oncology, CMS agreed with a comment from the American Society for Clinical Oncology (ASCO) that a law enacted in 2003 requires CMS to use the supplemental survey data from hematology/oncology. Accordingly, CMS will continue to use the PE/hr figure for hematology/oncology from the supplementary survey, instead of using the PE/hr from the PPIS. This slightly mitigates the decrease in practice expense payments to services commonly furnished by hematologists and oncologists, with CMS estimating that those 2010 aggregate payments to hematology/oncology will decrease 1% as a result of practice- expense changes. CMS estimates that hematology/oncology aggregate payments would have decreased 5% in 2010 if the agency did not phase in the new PE/hr figures over four years *********************************************************************** QUESTION: Should your initial chemo hour code be from the first drug you administer? We have a patient who gets Alimta/Carbo, the Alimta goes in first but our office codes it as a sequential push and Carbo as the initial. The nurses state that a few years ago they were told it didn't matter. Is this still correct? ANSWER: For the private practice physician, there is no requirement as to the order. Here is a direct quote from AMA CPT: "The order of selection for physicians is based upon the physician knowledge of the clinical condition(s) and treatment(s)." "When these codes are reported by the physician, the 'initial' code that best describes the key or primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur." While hierarchies have been created, they vary by location. According to AMA in the facility setting the initial code must be selected using a hierarchy whereby chemotherapy services are primary to therapeutics and infusions are primary to pushes. *********************************************************************** QUESTION: May we bill a concurrent infusion (96368) for Mannitol when it is mixed with Cisplatin? ANSWER: No. Since the Mannitol is “mixed” with the Cisplatin in the same bag, you could only bill for one administration. In order to bill for a therapeutic concurrent infusion, the concurrent drug must be in a separate bag. *********************************************************************** QUESTION: Can we bill for more than 1 quantity for code 96409? We give Intron, J9214 in 2 different pushes, one followed by the other. Is it true we can only bill for one administration? ANSWER: You state you are doing two “pushes” of the same Chemotherapy drug, J9214. The CPT directive is different for the therapeutic push versus the chemotherapy push add on code: Therapeutic push, 96375 states, “each additional sequential intravenous push of a new substance/drug” Chemotherapy push, 96411 states, “intravenous, push technique, each additional substance/drug” The chemo push code indicates the administration code e used for each additional substance or drug and does not require the drug to be a “new” drug. Therefore, it would be appropriate to bill for both pushes as long as the two pushes are medically necessary. *********************************************************************** QUESTION: In the middle of the chemotherapy treatment, our patient had a reaction. He received 1.5 hours of the 3 hour infusion. We had to stop the treatment for a period of time so the patient could receive a push of Benadryl. Once the patient was ok, we re-started the treatment which continued for another 1.5 hours. Do we bill the chemo treatment as an initial and then sequential infusion? ANSWER: No. This would be handled the same as you do for hydration before and after a cisplatin treatment, you would combine the infusion times and bill for one infusion. In this case you would bill for a 3 hour infusion, 96413 and 96415 x 2. *********************************************************************** QUESTION: We are an infusion center for Tysbri for MS and per the protocol, we are to hold the patient 1 hour after treatment and give them fluids, can we bill for them? ANSWER: If the fluids were "medically necessary" and documented as such, then it would be appropriate to bill for the hydration therapy. If you gave fluids because the patient was there and needed to be observed for the hour, and/or you needed to keep a line open in case they have a reaction, then no, it would not be appropriate to bill for the hydration therapy. *********************************************************************** QUESTION: Are we still supposed to use a modifier and HCT or HGB level when we bill for these meds after October 1, 2009? I was reading an article regarding the changes with diagnosis, but it did not mention if we are to continue with the modifier and HCT or HGB level. Please let me know. ANSWER: You are still required to use the HCT or HGB level as well as the modifiers. Effective January 1, 2008, all non-ESRD claims billing HCPCS J0881 and J0885 must also begin reporting one of the following modifiers: Modifier EA: ESA, anemia, chemo-induced Modifier EB: ESA, anemia, radio-induced Modifier EC: ESA, anemia, non-chemo/radio The changes to the diagnosis codes did not affect this policy. *********************************************************************** QUESTION: When Medicare updated the forth-quarter average sales price (ASP) files, adjustments were made to some of the third-quarter prices. Will Medicare automatically adjust our paid claims? ANSWER: CMS updates and publishes the ASP on a quarterly basis. In addition, CMS may intermittently publish a price adjustment that affects the previous quarter's data or the current quarter's data. Previously paid claims must be resubmitted to your local carrier for adjustment. Carriers sometimes allow the price correction through a telephone review but may require the claims to be resubmitted. Medicare's ASP pricing files and frequently asked questions relating to ASP can be found on the CMS Web site at http://www.cms.hhs.gov/providers/drugs/asp.asp. *********************************************************************** QUESTION: Has anyone heard of Medicare issuing a new rule that we cannot bill for a service after 30 days of that service? Where can I find information? ANSWER: Timely Filing of Claims To be eligible for Medicare reimbursement, claims must be filed within a qualifying time limit. Claims must be filed with Medicare by the end of the calendar year following the Fiscal Year, which runs from October to September, in which the services were provided, or the claim will be denied. To summarize, at least 15 months from the date of service are allowed for filing claims. Service Dates Claim Must Be Filed By 10-01-2005 through 09-30-2006 12-31-2007 10-01-2006 through 09-30-2007 12-31-2008 10-01-2007 through 09-30-2008 12-31-2009 10-01-2008 through 09-30-2009 12-31-2010 *Note: If a claim is filed more than one year from the date of service, payment to the physician or supplier will be reduced for that service by 10%. The provider cannot bill the patient for this reduction. The patient may only be charged 20% of the amount that Medicare would have approved for the service. Failure to File within Time Limits Valid claims not filed within the time limits are denied. The provider cannot collect the actual charge for the service from the patient when an assigned claim is denied for late filing. When the provider accepts assignment but fails to submit a valid claim within the filing limit, the patient may only be charged 20 percent of Medicare's approved amount. *********************************************************************** QUESTION: When we bill for chemotherapy we also bill the saline or D5W using the J-codes (J7050, etc). I recently heard that we cannot do this, is this true? Where do I find this information? ANSWER: ASCO clarifies this very well with the following example: Question: Given the scenario below, how do I code for the hydration during chemotherapy? 9:00 hydration starts 9:10 - 9:30 Decadron 9:40 - 10:15 Ca/Mg 10:20 - 12:30 Oxaliplatin 12:35 - 1:10 Ca/mg 1:15 - 2:20 Avastin 2:35 hydration ends 2:40---- 5fu prolonged Answer: The CPT manual states that, "when fluids are used to administer the drug(s), the administration of the fluid is considered incidental hydration, and is not separately reportable." The CPT manual also states that the intravenous start, if performed to facilitate the infusion or injection, is not separately reportable. Medicare rules state that hydration provided before or after a chemotherapy or non-chemotherapy is covered if reported with the -59 modifier. The modifier is an attestation that the hydration happened before or after the drug administration. In regards to the coverage of the saline itself, it is important to remember that Medicare does not typically cover supplies. In many cases, Medicare contractors have identified the amount of saline that is considered to be a supply. (Contractors sometimes use the quantity 250 or 500 mL of saline as the separation between a supply and a hydration therapy, but it is best to verify each contractor's/ payer's policy.) Saline that is used to flush a port or mix a drug may not be covered. When saline is administered for hydration therapy, the administration of the saline should be covered. (As mentioned above, under Medicare rules, hydration must occur before or after the chemotherapy in order for it to be covered.) The administration of saline in order to keep line patency, or to administer a drug, is considered incidental, and therefore, the administration of the saline would not be covered. In this scenario, the hydration time before the administration of chemotherapy totals 10 minutes, and the hydration time after the chemotherapy administration totals 15 minutes. Since neither of these hydration times total 31 minutes or greater, as required by the CPT manual to be able to report an initial hydration service, CPT code 96360, or each additional hour of infusion, CPT code 96361, the hydration is not a billable service. The hydration that is running concurrent with the administration of chemotherapy and supportive care agents is also not a billable service because the administration of saline is being used to either maintain line patency or to administer a drug. *********************************************************************** QUESTION: What is the difference between 96522 and 96523. I'm trying to explain to my physician. ANSWER: 96521, "Refilling and maintenance of portable pump" **Used when refilling and maintenance of a PORTABLE pump. 96522, "Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) " **Used when refilling and maintenance of an IMPLANTABLE pump. 96523, "Irrigation of implanted venous access device for drug delivery systems." **Used when flushing an implanted VAD (port flush) *********************************************************************** QUESTION: I have a patient on Vidaza. My nurse is giving this injection in two sights can I bill for 2 admin codes, such as 96409 qty of 2 or not? ANSWER: J9025: VIDAZA® can be administered intravenously or subcutaneously. According to the VIDAZA® package insert, for subcutaneous administrations of VIDAZA® where the dose is greater than 4 mL, the dose should be divided equally into two syringes and administered into two different sites. Since it is medically necessary to administer this drug in two injections, it is appropriate to use CPT 96401 x 2 when billing the payer. Please keep in mind that when this drug is administered as a short infusion (15 minutes or less), administration would be billed as 1 (one) chemotherapy push, CPT 96409. |
| The material presented on this site is intended as general information for WVOS members. Specifically, the information presented on this website does not represent medical advice, and it is not intended to increase or maximize payment by any payer. Because laws, regulations and coverage policies are complex and are updated frequently, you should check with your local Medicare carrier and payers often. Because diagnostic, treatment, contracting, and billing decisions should be made on a case-by-case basis, members are encouraged to contact their own consultants, lawyers or advisors to obtain specific advice on matters relating to contracting, coding, and billing and treatment. The information presented on this site should not be used as a substitute for such advice. |