ACM (previously ACT) B Questions and Answers - April 19, 2023

The following questions and answers (Q&As) are cumulative from the general Part B Ask the Contractor Teleconference (ACT). Some questions have been edited for clarity and answers may have been expanded to provide further details. Related questions were combined to eliminate redundancies. If a question was specific just for that office, Noridian addressed this directly with the provider. This session included pre-submitted questions and verbal questions posed during the event.

Updates and Reminders:

  • Ask the Contractor Meeting (ACM) acronym has replaced Teleconference (ACT)
  • If patient has managed care or railroad Medicare, instead of traditional fee-for-service Medicare, do not bill Noridian
  • Seek external sources for coding advice

PRE-QUESTIONS:

Q1. Can CPT 64719 unbundle from CPT 64721, if the OP report shows both the release of the carpal ligament and the Guyon's Canal was decompressed?
A1. Yes. Always check National Correct Coding Initiative (NCCI) edit combinations first, as the 64719 (ulnar nerve release) does bundle into 64721 (medial nerve release) with a "1" indicator. If the separate requirement for surgery, site, or injury is documented, this may allow modifier 59 to be appended on either code. Be sure your notes describe the extra work for performing the ulnar nerve release. Read more at https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicare/medicare-ncci-procedure-procedure-ptp-edits.

Q2. Can physicians performing interdisciplinary rounds include "discussion of management with external physician" as a data component to determine level for evaluation and management (E/M) service?
A2. Yes. CPT guidelines definition for an external physician or other qualified health care professional is not in the same group practice or is of a different specialty.

Q3. Can we bill an office visit for a patient seen in our office when they are listed as inpatient at a skilled nursing facility (SNF) or rehab hospital?
A3. Yes. Providers can bill Part B for a separate "office" visit, as the SNF Consolidated Billing does not bundle office visits into the Part A stay. When the service is rendered to a patient, registered as an inpatient in a rehab hospital or SNF, regardless of where the face-to-face encounter occurred, place of service (POS) 21 or 31 is billed, instead of POS 11 (office). Read more at https://www.cms.gov/medicare/snf-consolidated-billing/2023-part-b-mac-update. The Internet Only Manual (IOM) excerpt explains https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26pdf.pdf.

‘When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered inpatient, the appropriate inpatient POS code may be reported consistent with the code list annotated in this section (instead of POS 21). For example, a physician/practitioner may use POS 31, for a patient in a SNF receiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpatient Facility, and POS 61 for patients registered in a Comprehensive Inpatient Rehabilitation Facility.’

Q4. When performing a Neurogram, do we bill individual MRI CPTs or an unlisted code?
A4. The MRI Neurogram scan would involve CPT 76498 (Unlisted magnetic resonance procedure, when specified as magnetic resonance neurography). More information under the National Coverage Determination (NCD) 220.2 titled Magnetic Resonance Imaging (MRI).

Q5. When billing unlisted CPT codes what type of documentation should be submitted to support medical necessity and reimbursement?
A5. Under Noridian's Browse by Topics, Documentation Requirements, there are specific requirements for specialties and topics. These include checklists to assist and no need to send documentation, unless asked. Enter a well-defined description of the procedure and how it differs from available codes in Item 19, or the electronic equivalent. Medicare may ask for additional records to support the service. Providers can fax, mail, or utilize the electronic additional documentation Paperwork (PWK). Read more under Browse by Topic, Claims, General, PWK at Jurisdiction E (JE) B https://med.noridianmedicare.com/web/jeb/topics/claim-submission/pwk or JFB https://med.noridianmedicare.com/web/jfb/topics/claim-submission/pwk.

Q6. How many days count time towards an E/M visit for office or outpatient services?
A6. Time is limited to the date of the patient's visit. CMS includes time required to bill the office or outpatient code. Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.15.1.F at https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf. Updates for 2023 found in change request (CR) 13064 at this link: https://www.cms.gov/files/document/r11842cp.pdf.

Q7. Does Medicare have a "Patient Order's" template or guidelines for ordering Radiation Therapy from a free-standing radiation clinic?
A7. No. The use of order forms can vary for each clinic and Medicare does not have guidelines for template use. It is important that the medical record reflects the need for care and services provided. The provider's signature supports evidence that the order is correct. Please refer to the Radiation Therapy Documentation Requirements page on our website under Browse by Topic, Documentation Requirements, at Radiation Therapy.

Q8. Do two separate offices within the same building qualify as the same "office suite"?
A8. This depends. We consider "office suite" as limited to the dedicated area, or suite, designated by records of ownership, rent or other agreement with the owner, in which the supervising physician or practitioner maintains his or her practice or provides his or her services as part of a multi-specialty clinic.

If the diagnostic imaging center is separate from the supervising provider's dedicated office area, then the physician would need to be in attendance in the imaging center to qualify as "direct supervision". For direct supervision, the physician does not need to be in the same room during the procedure.

Q9. Does a patient with dementia or medically decompensated need to be present to bill an office visit, when the caregiver, family, or durable power of attorney (DPOA) are present to discuss patient issues?
A9. Yes. The patient would need to be present for a majority of the visit to bill for the service. The caregiver or power of attorney may present with the patient. Per CMS IOM Publication, 100-02, Chapter 15, Section 30. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c15.pdf

Q10. Which E/M code category should be used by the other physician (not the primary treating physician) evaluating the patient in observation status?
A10. Other practitioners providing evaluation services to a patient in observation would submit the appropriate outpatient E/M service codes with the correct place of service. Per CR 13064 and under Section 30.6.8.B at https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf

Q11. Are Transitional Care Management (TCM) CPTs (99495 and 99496) medical decision-making (MDM) determined by 2023 audit tool for office visits or ‘95 guidelines for office visits?
A11. MDM for TCM CPTs 99495 and 99496 determine moderate or high-level MDM for the current medical and psychosocial needs. Follow the current guidelines, providers need to consider the following factors:

  • Number of diagnoses and management options;
  • Amount and complexity of records, tests, reviewed and analyzed; and
  • Risks and possible management options.

For additional information, read page 11 of the August 2022 CMS TCM Medicare Learning Network (MLN) Booklet at https://www.cms.gov/files/document/mln908628-transitional-care-management-services.pdf

Q12. If a Botulinum toxin vial is split between two patients, how will providers incorporate JZ modifier when required on July 1, 2023? For example; if a provider treats with 250 units of the toxin, uses a 200-unit vial in its entirety and 50 units from a 100-unit vial?
A12. Per Noridian Local Coverage Article (LCA), providers will complete this information on one line, as compared to two lines for modifier JW that indicates wastage. Use the applicable HCPCS code, append the JZ modifier to indicate there was no wastage, and the number of units provided to the patient. Lastly, calculate the submitted price for the amount given. CMS also has published a great FAQ regarding the JW and JZ modifier at this link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf.

Q13. Does the patient need to be present for Psychiatric Diagnostic Assessments (CPT codes 90791 and 90792)?
A13. Yes. Due to Medicare changing the focus to the patient, the beneficiary must be present for "most" of the session for all mental health codes.

Q14. Are both a pain assessment and disability scale required for the Facet Joint Interventions for Pain Management Local Coverage Determination (LCD) policy?
A14. Yes. The pain scale would be used for diagnostic injections. For therapeutic injections, one can use pain OR disability scales. If planning to assess disability going forward with therapeutic injections, then at the very beginning, when performing diagnostic injections, use both pain AND disability scales. This allows a baseline for disability to be used following each therapeutic injection if that is the treatment plan to follow. If providers only using the pain scale, then you don’t need the disability. The problem may start with one and then use the other interchangeably, and there is no baseline for comparison.

Q15. Our Ambulance provided emergency transport to a Part A resident of a Skilled Nursing Facility (SNF). Can you explain why only Ambulance mileage was paid and not the base rate?
A15. Inpatient and consolidated billing denials are managed by the Common Working File (CWF). We are unable to review the processing of a claim on this call. Please work with the contact center if you have not already. In accordance with IOM 100-04, Chapter 6, Section 20.3.1, an ambulance transport to Critical Access Hospital (CAH) and back to a SNF is only payable when the patient is receiving emergency or other excluded services outlined in section 20.1.2 of this manual.

Q16. If the provider, not the independent trained observer, performs CPT 99152 for moderate sedation, can we use the RN's documentation not signed by the MD to code? Often, the MD will document time, drugs administered, but not name and credentials of the observer.
A16. Moderate sedation documentation must have the independent trained observer; Nurse Practitioner (NP), Physician Assistant (PA), or Registered Nurse (RN), whose sole duty is to monitor beneficiary's level of consciousness, physiological status and must be present throughout entire diagnostic or therapeutic service. Their name and credentials must be identified in the notes.

Q17. What are the administration CPTs for magnesium sulfate for infusions, hydrations or pushes and is the drug billable? Are there specific diagnoses needed?
A17. Read Noridian's Local Coverage Article (LCA) JE A54635-https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=54635) or JF A52732-https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52732) titled Billing and Coding: Hydration Services that show CPTs 96360 (Intravenous Infusion, hydration; initial, 31 minutes to 1 hour) and on CPT +96361 (Intravenous Infusion, hydration; each additional hour) may be billed. Documentation of the assessment should describe symptoms warranting hydration, such as those associated with dehydration, the inability to ingest fluids or clear clinical contraindication to oral intake, abnormal fluid losses, abnormal vital signs, and/or abnormal laboratory studies, such as an elevated BUN, creatinine, glucose, or lactic acid.

Q18. Can an attending or supervising physician receive credit in data for an independent review of an image noted by the resident without actual independent review by the attending?
A18. No. CMS will allow an interpretation of diagnostic radiology or other diagnostic tests under the Medicare Physician Fee Schedule (MPFS), when performed by a physician other than a resident. When a resident is interpreting diagnostic radiology or other tests in a residency training site outside the Metropolitan Statistical Area (MSA), the teaching physician must be present through audio or video real-time technology. The medical records must show the physician took part in interpreting diagnostic radiology tests. If the attending physician did not provide the interpretation, they would not receive credit. May 2022 resource https://www.cms.gov/files/document/guidelines-teaching-physicians-interns-and-residents.pdf.

Q19. If an Ophthalmologist notes a problem in the history and examines the patient, is that enough to consider it a problem addressed? What should be documented to support?
A19. To bill an E/M 992xx series, there must also be either time reflected or medical decision-making (MDM). Documentation needs to follow the 2021 guidelines. Guidelines include preparing for the visit (such as reviewing tests); reviewing history that was separately obtained; performing the exam; counseling and providing education to the patient, family, or caregiver; ordering medicines, tests, or procedures; communicating with other healthcare professionals; documenting information in the medical record; interpreting results and sharing that information with the patient, family, or caregiver; and care coordination. Total time does not include time for clinical staff activities they normally perform.

Q20. Medical Nutritional Therapy (MNT) CPTs 97802 and 97803 (assessment or re-assessment) show billing for each 15 minutes. Can we use the time-based guideline for the 8-minute rule thresholds?
A20. Yes. With the time-based rule, one unit = 8-22 minutes and is attained when the midpoint is passed. For 97802 and 97803, at least eight minutes would need to be spent in order to bill.

Q21. Can you clarify the documentation requirements for both the physician and NP or PA for shared visits when using time as the substantive?
A21. Medical record documentation will be used to objectively determine the medical necessity of the visit and accuracy of documented time spent. Time can be documented with either start and stop time or total time. CMS has not indicated if stating "more than 50% of time spent" would be supporting the time requirement. Under the split or shared visit in a facility, if the non-physician practitioner spent less time than the physician, it would be correct to bill under the physician's name. Documentation would need to support the time indicated for each provider, either by start and stop time or total time. The substantive portion may also be determined by three key components of the E/M visit: history, exam, or medical decision-making.

Q22. Can HCPCS G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact) be reported for time spent on the same day or even time on a different day?
A22. HCPCS G2212 includes time spent only on the date of the encounter. It's only added to an E/M CPT 99205 or 99215 for clinician time only. The full 15-minutes or maximum time must be met to bill G2212. Medicare Administrative Contractors (MACs) will process claims per the IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.15.

Q23. Does Medicare reimburse for HCPCS G0323 if billed by a Licensed Clinical Social Worker (LCSW)? Can the same 20 minutes of care management time spent for G0323 count toward the required time for CPT 99493, Coordination of Care Model (CoCM), 60 minutes) billed under the primary care physician?
A23. Per CMS’ recent January 2023 MLN 909432 article: Behavioral Health Integration (BHI) Services, https://www.cms.gov/files/document/mln909432-behavioral-health-integration-services.pdf, included now are a clinical psychologist (CP) or licensed clinical social worker (LCSW) that can perform to account for monthly care integration. They can also serve as the focal point of care integration that furnishes the mental health services. Therefore, at least 20 minutes of CP or LCSW time (per calendar month) would only be able to be billed for Behavior Health Integration (BHI), and not shared with other care management types. They can both enroll and bill directly as long as they are part of the primary team and follow all of the required elements.

Q24. If the Resident admits a patient late night and the Nephrologist sees next day as a split/shared visit with the Advance Practice Provider (APP) that includes NP, PA, certified nurse midwife (CNM), advanced practice registered nurse (APRN), and certified registered nurse anesthetist (CRNA). Does the Nephrologist bill initial and include the resident's notes for additional documentation? Is modifier FS approved or are both modifiers FS and GC on same line?
A24. For all split (or shared) visits, one of the practitioners must have face-to-face (in-person) contact with the patient, but it does not necessarily have to be the physician or practitioner, who performs the substantive portion that bills for the visit. The physician or practitioner providing the substantive portion would bill for the visit, sign, and date the medical record.

If billing based on time, documentation needs to support time for both providers involved. Documentation in the medical record must identify the physician and NPP who performed the visit. Modifier FS is appropriate if related to the E/M split and shared services. Modifier GC (for resident E/M codes under direction of teaching physician in approved teaching program), would not be appended on the split and share visit, since the resident was not part of the second day visit. GC is all about teaching physicians.

Read more at https://www.cms.gov/regulations-and guidance/guidance/manuals/downloads/ clm104c12.pdf under CMS IOM Publication 100-04, Chapter 12, Section 30.6.18 that explains split and share services with the new January 2023 E/M guidelines. It includes an example with the Non-Physician Practitioner (NPP) or APP.

Q25. Can status indicator "M" be billed to Part B on a CMS-1500, as it's defined as not paid through the Outpatient Prospective Payment System (OPPS) or not billable to Part A or Durable Medical Equipment (DME)?
A25. Depending on the drug, it may be covered under Part B or even Part D. Check the Part B Fee Schedule, under Indicator List and Descriptors to research. We will have a MPFS webinar next Friday. On the CMS webpage, Part B covered drugs are located at https://www.cms.gov/medicare/payment/all-fee-service-providers/medicare-part-b-drug-average-sales-price/vaccine-pricing.

Q26. Which payment methodology is used with new drug code pricing for not otherwise classified (NOC) J codes (J3490, J3590, J9999, C9399)?
A26. Unlisted J-codes are paid based on Wholesale Acquisition Cost (WAC) plus 3 percent.

Q27. How should services be billed with higher units than allowed by the Medically Unlikely Edit (MUE)?
A27. MUE billing is either a) line item edit with MUE Adjudication Indicator (MAI) of 1 or b) per day edit of MAI-1 or MAI-3. If it’s a line edit and providers bill over the allowed number of units, the whole line will deny. You could appeal if it’s an allowed amount. Providers can bill two lines with modifier 76 appended on the second line. Either way, you can’t charge the patient for the overage. If per day edit, bill one line, services will deny and providers may appeal. Make sure that documentation supports. Read more at https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicare/medicare-ncci-faq-library#mue.

Q28. Which E/M codes should modifier AI (Principal Physician of Record) be appended?
A28. Modifier AI would be appended to the initial visits only (hospital, skilled nursing facility or nursing facility). By appending AI, the principal physician of record will be identified as the admitting physician. Modifier AI should never be appended to subsequent visits.

Q29. With the new 2023 E/M coding guidelines for inpatient and observation visits, do we use the initial hospital inpatient codes (99221-99223) for an initial inpatient consultation? Can only the admitting physician bill observation codes, while consultants bill outpatient or office visit codes?
A29. Medicare doesn't cover consultation codes. Physicians from a different group or specialty, providing an E/M service to the patient, which has been admitted by another physician, submit an initial hospital or observation E/M code when seeing the patient for the first time during the hospital encounter. If seeing the patient for subsequent visits, use the appropriate subsequent codes. The treating practitioner bills observation care codes. All other practitioners seeing the patient during observation would bill the appropriate outpatient service codes. See CR 13064 and CMS IOM 100-04, Chapter 12, Section 30.6.8.B.

Q30. With the COVID-19 emergency ending, do patients need an in-person visit with providers, prior to a sleep study, or will telehealth be acceptable as part of 2023 Consolidated Appropriations Act (CAA) that goes to the end of 2024?
A30. While Sleep studies are not addressed specifically in the Telehealth waiver, in the CY 2023 Final Rule, CMS finalized alignment of availability of services on the telehealth list with the extension timeframe enacted by the 2022 CAA. The 2023 CAA further extended those flexibilities through CY 2024. Here’s the updated CMS Public Health Emergency (PHE) flexibilities FAQ updated May 5, 2023:

VERBAL Q/A:

Q31. How do providers use JW modifier with an unlisted code and document what was wasted?
A31. Make sure all your narrative and documents supports modifier JW and it’s applicable to single-dose drug. Follow the unlisted code with Box 19 requirements.

Q32. Where can I find a list of all drugs with status N1 indicator with the JZ modifier?
A32. The indicator is on the Outpatient Prospective Payment System (OPPS) site. Only single dose vials may include wastage with JZ modifier appended. There is not a specific list of injections that require the modifier.

Q33. What kind of medical necessity is required to report CPT 93281 (programming device evaluation in-person; with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional multiple lead pacemaker system) with modifier 90 (sent to reference lab) for reprogramming vs. what seems like a routine interrogation code situation? Reprogramming is a higher level code that requires medical necessity. What is the difference between interrogation and reprogramming?
A33. The difference between the two is that interrogation involves evaluation up to 90 days and re-programming requires an indication. As you know, these codes are reported for patients with pacemakers, implantable defibrillators, implantable loop records (ILRs), or subcutaneous implantable defibrillators for in-person programming device evaluation. Reprogramming requires an indication. Interrogation is part of routine E/M, but a separate procedure.

This CPT does not qualify for modifier 90 per Anti-Markup rules that do not apply. Principles of the CPT coding book that AMA publishes. CPTs 93270-93285 are used to report customized program evaluations. These codes are reported when all device functions, including the battery, programmable settings, and leads(s), when present, are evaluated. The final program parameters may or may not be changed as a result of the evaluation.

Q34. Would Modifier 25 be appropriate in a care center to evaluate a laceration repair (minor procedure)?
A34. In new patient visits, it doesn’t automatically mean providers have a separate E/M with the procedure, as the documentation would need to support. E/M visits bundle into laceration repairs (CPT 12001-12007); however, modifier 25 is appropriate per the NCCI edits of indicator 1. Place of service is not a deciding factor when appending modifier 25.

Q35. Since the PHE is ending, will we stop using the CS modifier as of May 11, 2023?
A35. Yes. The CS modifier is applicable to any emergency (designated emergency – waiver applied), it will no longer be allowed after the COVID PHE ends on May 11, 2023.

 

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