Article Detail - JE Part A

Written Questions

Q1. Regarding procedure G0260 (Injection procedure for sacroiliac joint) are you required to report either 77002 (Under fluoroscopic guidance) or 77012 (Under computed tomography guidance) with this procedure?
A1. CPT 27096 (Under introduction or removal procedures on the pelvis and hip joint) is not a covered service for Ambulatory Surgical Center (ASC) facility (specialty 49) claims and is not recognized under Outpatient Prospective Payment System (OPPS). ASC facilities and OPPS hospital outpatient departments should report HCPCS code G0260 for sacroiliac joint injections. The medical record must contain documentation that fluoroscopic guidance or CT guidance was used with HCPCS code G0260. Image guidance is packaged into G0260, and no separate payment is made to ASC or OPPS hospital outpatient department for CPT 77002 and 77012. 77002 and 77012 are imaging codes that are added to G0260 to specify the imaging modality used for guidance (fluoroscopy or CT scan). See Billing and Coding article, A59246: Sacroiliac Joint Injections and Procedures.

Q2. Regarding respiratory therapy CPTs 94667 (Under pulmonary diagnostic testing and therapies) and 94668 (Under pulmonary diagnostic testing and therapies), we have been billing under revenue code 0410. Staff here are stating they are getting a denial that it is reported under revenue code 0657. Is this a correct denial?
A2. There was a September 2024 local system file update by Noridian to allow these codes with revenue codes 0410, 0412, and 0419. If the claim was submitted prior to the September adjustment, that is why these claims would deny. Providers should resubmit the applicable claims.

Q3. For positron emission tomography (PET) scan code 78814 billed in conjunction with radiopharmaceutical HCPCS A9601, Noridian Returns to Provider (RTPs) the claim with reason code 32440. HCPCS A9601, Flortaucipir F-18, is a diagnostic radiopharmaceutical used with PET scans of the brain. Why is this code not an acceptable HCPCS code for the PET scan of the brain?
A3. In one claim example Noridian reviewed as a part of this question, no tracer was billed on the claim. Be sure to bill the appropriate tracer line item, as claims will Return To Provider (RTP) if no tracer is billed. Noridian is updating a local system edit to allow for HCPCS A9601. Once this edit work is complete, watch for notification on the Noridian website. These claims can either be resubmitted (F9), or providers can call the Provider Contact Center for assistance.

Q4. How to bill for inpatient rehabilitation facility (IPF) inpatient days when patient has zero full days and two lifetime psychiatric days remaining?
A4. If the patient does not have any full, co-pay, or lifetime reserve (LTR) days available, regardless of if they have lifetime psych days, they will bill the entire claim as benefits exhaust. To use the lifetime psych days, the patient must have one full, co-pay, or LTR day to match (1 to 1 ratio) for the freestanding psych facilities. The Distinct Part Units do not use lifetime psych days so that would not apply to them.

• Fully non-covered claim for benefits exhaust
• Type of Bill 110
• Value Code 81 with all days as non-covered
• All units and charges on all revenue codes as non-covered
• Enter remarks stating, "Billing for benefits exhaust."

There is more information to be found in the Internet Only Manual (IOM), Publication 100-04, Chapter 3, Section 40.3 as well as the IPF page on our website.

Q5. Comprehensive Error Rate Testing (CERT) auditors are denying left atrial appendage occlusion (LAAO) claims for shared decision-making elements that are not indicated in the National Coverage Determination (NCD) or Decision Memo. Are there NCD updates in progress to define share decision making between all NCD that have this requirement? The documentation expectations are not aligned.
A5. In its Decision Memo CAG-00445N, CMS interchangeably uses the terms left atrial appendage closure (LAAC) and left atrial appendage occlusion (LAAO).

Missing the formal shared decision-making component is a common error across all CERT reviews. In NCD 20.34, Percutaneous Left Atrial Appendage Closure (LAAC), under the Nationally Covered Indications, LAAC is covered under certain conditions. One of these includes "A formal shared decision-making interaction with an independent non-interventional physician using an evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. Additionally, the shared decision-making interaction must be documented in the medical record."

If there are examples where the CERT has denied claims for "shared decision-making elements that are not indicated in the NCD or Decision Memo" Noridian would need to see examples where this is occurring.

Any updates to the NCDs are communicated directly by CMS and recommunicated afterwards by the MACs. Currently there are no updates in progress for this NCD.

Q6. CPT 92972 (Coronary lithotripsy) is an active CPT code for Medicare but is this considered a non-covered service? This is an add-on code with no additional reimbursement but there are questions surfacing through Part B denials regarding medical necessity.
A6. On the Part A side, this is a covered service. This code does have a Status Indicator of N in the OPPS Addendum B, which means that the payment for the code is packaged into payment for other services (wrapped into the payment of the primary code). Therefore, there is no separate ambulatory payment classification (APC) payment on the Part A bill. On the Part B bills, you would want to call our Provider Contact Center to inquire about the denial codes.

Q7. We have several claims billed for J0585 (Botox) that are denying, indicating that an additional code is necessary for payment. Our coding department has reviewed the reference article A57185, and we do not believe that coding is missing, as the claims included a covered diagnosis (K22.0) and CPT code (43236) (Under esophagogastroduodenoscopy) from Group 2. Can you explain why these codes are not being paid?
A7. Thank you for your submission on this issue, as it is timely information. This issue was something our Medical Policy, Contractor Medical Director, and Systems team recently worked on together to fine tune claims editing. Noridian's systems have been updated to allow the 43236 as an acceptable administration code. Providers who have RTP claims can simply resubmit them (F9) for reprocessing. Providers who have rejected or denied claims may call our Provider Contact Center for their jurisdiction to have Noridian reprocess the claims.

Q8. I am seeking clarification on the appropriate billing process for the professional component (PC) of radiology services in a Federally Qualified Health Center (FQHC) setting when the interpretation is performed by a contracted radiologist. Specifically, can the FQHC bill Medicare Part A for the professional component (PC) of the radiology service under its provider number when the radiologist is contracted to provide interpretations on behalf of the FQHC? If so, are there specific requirements that must be met (e.g., formal contract terms, revenue codes, place of service considerations, etc.)?

Additionally, if the FQHC cannot bill for the professional component, should the contracted radiologist bill Medicare Part B directly, or is there another billing arrangement that should be followed?
A8. Radiology services in FQHCs are not separately payable under the FQHC PPS. The technical component (TC) is billed separately to the MAC and must follow CMS' commingling policy. Costs for contracted providers are reported as direct and indirect costs on the FQHC cost report. The professional component (PC), billed with Modifier 26, is bundled into the FQHC encounter payment during a qualifying visit. FQHCs handle billing for both components for contracted radiologists.

Verbal Questions

Q9. We are also having issues getting claims accepted when Botox is given through laryngoscopy (either flexible or direct). CPT 31570 is listed in the LCD but it tells us it needs to be billed with another code. Also, why isn't 31573 included in the billing article?
A9. The list of ICD-10-CM codes that support medical necessity for botulinum toxin are listed in the Group 1 section of Billing and Coding article A57186. Per review, CPT 31570 is not deemed an appropriate administration code for botulinum toxin injections.

There are more appropriate codes that describe chemodenervation that could be utilized and allow the claim to process. If the provider believes CPT 31570 is the appropriate code for use on this claim, they will need to submit an appeal for review.

Billing and Coding: Botulinum Toxin Types A and B (A57186)

Q10. Regarding patient rights to appeal inpatient discharges, we have several patients contacting Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO), Livanta, but nobody is answering, and the voicemail is full so they cannot make their appeal requests. Will Noridian pay for the continued stay as if the patient made the appeal, even if the patient attempted to appeal but it was not received by the BFCC QIO? If so, what are the documentation requirements to show the attempt was made? If not, can the hospital continue with discharge and/or notify the patient that they are personally responsible for the charges for the continued stay?
A10: If patients can't reach the BFCC QIO to appeal due to full voicemail or no response, Noridian may treat the continued stay as if the appeal was made, provided there's enough documentation. This includes records of all contact attempts (dates, times, methods) and a written statement from the patient or their representative. If the appeal isn't received, the hospital can discharge the patient if they are medically stable. Inform the patient of their right to appeal, steps to take if unable to reach the BFCC QIO, and potential financial responsibility for the continued stay. Clear communication about financial implications and assistance options is crucial. If the BFCC QIO is consistently unresponsive, consider escalating the issue to CMS. Thorough documentation and clear communication help protect patient rights and address billing issues.

Of note, there are two new appeals processes, one of which is retrospective, implemented by CMS for 2025 resulting from the Alexander v. Azar decision. CMS has the details posted on its website for providers and beneficiaries.

Hospital Appeals - Change of Inpatient Status (Alexander v Azar)

Q11. The description of code G0463 (Hospital outpatient clinic visit for assessment and management of a patient) states it's a hospital outpatient clinic visit, but can it also be used in hospital outpatient department that is not necessarily labeled as a clinic? Is the code still valid to bill as a part of telehealth in the post-PHE?
A11. CMS does not have an abundance of material published to answer this question. However, it does appear in a 2023 (last updated) COVID-19 FAQ as Question #3 on page 167, explaining CMS's intent. "HCPCS code G0463 describes a clinic visit furnished in the hospital outpatient setting when the practitioner and the patient are both located within the hospital." Noridian believes that this would require other coding if the assessment and management service were to occur in a different department setting. CMS ended the PHE waiver extension for billing the G0463 in 2023 as telehealth service, requiring that both the patient and practitioner be present at the hospital. (See the second FAQ linked below, Question #17 on page 7.)

COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing

CMS Waivers, Flexibilities, and the End of the COVID-19 Public Health Emergency

Q12. Since outpatient hospital departments may move around, does the enrollment file need to specify a suite number for on-campus or off-campus? When we update the address, do we have to include the exact suite number?
A12. Any time there is an address change, even as small as a suite number, those should be made in the system. The claims processing system checks against PECOS when processing claims. If billers are typing in a new suite number and it differs from PECOS, that could cause a problem in processing. To the second question… This is a business decision; however, CMS does want the addresses as detailed as possible.

Q13. Regarding my written question on radiologists performing the professional component, does the radiologist have to be credentialed under our National Provider Identifier (NPI)? In the past, we've obtained a roster from the company credentialing the radiologists but we are wondering if we should be credentialing them since we are contracting the service with them.
A13. (Noridian clarification question: Are the radiologists a group on their own and the FQHC contracts with them for technical components? Answer: Yes.) The radiologists should be credentialed with the FQHCs. This ensures they meet the necessary qualifications and standards to provide the high-quality care. Credentialing is important for maintaining compliance with Medicare and Medicaid regulations, as well as ensuring patient safety and quality of care. It helps FQHCs meet accreditation requirements and maintain their status.