Article Detail - JE Part B

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:

• Public Health Emergency (PHE) signed again October 13, 2022 for additional 90 days (now January 13, 2022)
  • CMS pledged to notify 60 days prior to expiration
• Check the 2023 "CMS Final Rule" and stay tuned for Noridian implementation from CMS directives
• Provider Customer Service (PCC) reminds providers of busy call times from 11am - 2pm Central
• Don't share Noridian's PCC number with patients as they must call 1-800-Medicare
• If patient has managed care, instead of traditional fee-for-service Medicare, do not bill Noridian
• Seek external sources for coding advice

PRE-QUESTIONS:

Q1. The American Society of Echocardiography (ASE) requests an editorial correction to add on CPTs 93325 (doppler echocardiography) and 93319 (3-D echocardiography) because the National Correct Coding Initiative (NCCI) does not allow those billed together. Will Noridian allow this current billing?
A1. No. Those claims, with 93319 and 93325 billed together, will continue to deny as Noridian Medicare must follow all NCCI editing. If this bundling changes in 2023, providers will be notified.

Q2. Can you differentiate Critical Care time reported by multiple providers in the same specialty and group practice?
A2. Yes. When the visit is split or shared between a physician and a non-physician practitioner (NPP), the practitioner who provides the substantive portion of accumulated time (greater than 50% of the time) would bill the critical care service with modifier FS, per CMS IOM Publication 100-04, Chapter 12, Sections 30.6.12.5 and 30.6.18.

CMS allows critical care to be performed on a single date of service by one physician or practitioner, or by a combination of providers in a group; including both physicians and nonphysician practitioners (NPPs). The total time spent providing critical care services by a single or multiple practitioners determines the billing for those services. This means that the full timeframe for each code must be met to add it to the claim. In critical care for 99291, 74 minutes must be spent. To report additional time, another full 30 minutes of time spent is required for 99292, totaling 104 minutes to bill for the two codes. Each 30-minute segment beyond that time, supports an additional unit of CPT 99292.

Q3. Is there guidance for second interpretation when a Radiologist requests a second reading of an image, other than CMS Internet Only Manual (IOM) Publication 100-04, Chapter 13, Section 100.1, when the initial reading was from an outside image center?
A3. Yes. Medicare pays for only one read unless it's medically necessary to have an additional read. Medical necessity must be documented when a second reading of the image is to be considered for reimbursement. The second report must clearly state the purpose of the interpretation, with the name of the ordering provider requesting the new and second interpretation. Modifier 77 (repeat procedure by another physician) could be appended to the second radiologic interpretation code. See CMS IOM Publication 100-04, Chapter 16, Section 100.5.

Q4. When an interventionalist performs an add-on CPT 93571 (flow wire-FFR) or 92978 (endolumnil ivus) to the cardiologist's performing a diagnostic catheter (both part of the same group), during the same session in the catheter lab; how can we bill and be reimbursed appropriately?
A4. If cardiac procedures are billed by two different providers, the second provider should not bill for the add on CPTs (+92978 or +93571), as there must be a primary or parent CPT (e.g., 93454-93461) to bill add on codes on the same claim. Occasionally, billing an undifferentiated (unlisted) code and indicating exactly what is being performed may help. If this meets the co-surgeon requirement, both providers must append modifier 62 to their claims. Please check with your respective societies to resolve nationally.

Q5. What guidelines are there regarding pre-charting of progress notes, date of entry limitations, content, and new templates? Are scribes, non-physician practitioners, and medical assistants allowed to provide note pre-preparation?
A5. Yes. Any staff can provide documentation in the medical record when effectively authenticated by the billing provider's signature, with date and time. CMS does not require the scribe to sign or date the documentation. Documentation needs to support the service(s) submitted to Medicare. All services provided are expected to be documented at the time they are rendered. More information can be found in the CMS Complying with Medicare Signature Requirements Fact Sheet.

Q6. Can clinical staff provide Advance Care Planning (CPT code 99497) under the order and medical management of the billing provider?
A6. Yes. Clinical staff can perform Advance Care Planning, using a team-based approach, under the order and medical management of the billing provider. The 2016 Federal Register 2016 Final Rule provides the answer. CMS published the Frequently Asked Questions about Billing the Physician Fee Schedule for Advance Care Planning Services and the CMS MLN Advance Care Planning Fact Sheet, referencing the 2016 Final Rule.

Q7. Is it fraudulent billing if the lab claim first denies with diagnosis (Z00.00-encounter for general exam without complaint, suspected or reported diagnosis) for CPT 80061 (lipid panel) and then, since the lab order included E78.2 (mixed hyperlipidemia), the lab rebilled with just that diagnosis and not the noncovered ICD-10 Z00.00?
A7. No. If the ICD-10 E78.2 was erroneously omitted, and clearly documented beforehand, including why the test is performed, the claim could be reopened or appealed to add the additional diagnosis. If a provider is sending the lab an order with a diagnosis of Z00.00, it's beneficial for the lab to contact the provider, before billing, to ensure the correct order was sent. Do not omit the Z00.00; just do not point it as primary diagnosis in billing. The patient may be examined for hyperlipidemia and viewed for hypertension if the physician is monitoring patient with known condition. In this claim example, link CPT 80061 to the diagnosis E78.2 to resolve the issue.

Q8. Some Local Coverage Articles (LCAs) do not have an associated Local Coverage Determination (LCD). Can we have the Noridian Medicare Portal (NMP) link to LCAs like the NMP offers for LCD policies?
A8. Thank you for your suggestion and our Medical Policy and NMP teams will address adding those links. As a reminder, not all LCDs have LCAs and vice-versa.

Q9. Where can I locate medical necessity documentation for a particular CPT and when billed in conjunction with the same or opposite breast sites (i.e., CPTs 15877, 19316, 19318, 19342, 19370)?
A9. Under Noridian's home page, Browse by Topic, there's great JEB Documentation Requirements information. Check if a CPT or HCPCS has a National or Local Coverage Determination policy (NCD or LCD) with matching Billing and Coding articles. Researching your specialty and medical associations for guidance is also helpful. The CMS National Correct Coding Initiative (NCCI) edit webpage provides rational as to which codes are mutually exclusive, bundled and why. Always check each code combination.

Q10. How is the payment calculated with multiple procedure payment reduction (MPPR) for outpatient therapies speech language treatment (CPT 92507) and 30 minutes of therapeutic exercises with a physical therapist (CPT 97110, each 15 minutes)?
A10. These are therapy services with a multiple pricing indicator of 5. This means when multiple therapy services are billed on the same date of service, the first unit of service with the greatest allowance will allow at 100% of the fee schedule amount. There is a 50% reduction for the next procedure's practice expense only provided to the same patient on the same day. Do not append modifier 51 as the processing system auto-calculates.

This reduction is applied when more than one unit or therapy procedure is provided to the same patient on the same day. This applies to all therapy disciplines, not just one. It applies to the HCPCS codes contained on the list of "always therapy" services that are paid under physician fee schedule. More specific information is available within the CMS Change Request (CR) 8206 and Noridian's JEB Fees and News/Fee Schedules/Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services webpage.

Q11. We have orders, procedures, and other supplemental information (scanned paper documentation with the providers signature, date, and time), indicating it was the same patient encounter as the typed note and is clearly in the Electronic Medical Record (EMR). Can it be used to support reporting a service with claim submission, even if the provider did not mention in their note?
A11. Yes. For providers billing Medicare, the documentation must be present in the patient records. These records must be legible, and the provider signs each entry, with clear and concise information that reflects the patient's condition and provides sufficient detail to support necessity for diagnostic test. This should be created at the same original time.

Q12. Can the drug name and dosage be used in the E-order to supplement the clinical note for Evaluation and Management (E/M) moderate risk level determination?
A12. Yes. The drug and dosage can supplement the clinical note in an E-order. The clinical note needs to reflect the drug management and moderate risk of morbidity.

Q13. Is tissue removal the only deciding factor for biopsy and would billing involve CPT 11300 rather than CPT 11102?
A13. No. The term biopsy would not be the only decision factor. Physicians clearly need to indicate the purpose of the procedure. 11102 is a biopsy where a sample of tissue is taken for diagnostic pathology examination. The 11300 is a therapeutic, complex removal of symptomatic epidermal or dermal lesion of 0.5 cm diameter or less (also known as an epidermal lesion shaving).

Q14. When performing a bronchoscopy, via endotracheal tube, would you append a modifier 52 for reduced services?
A14. It would depend on the documentation and reason for reducing the procedure. In determining whether to append modifier 52, review the Noridian JEB, Browse by Topic, Modifiers page, as it explains correct uses, incorrect uses, examples, and resources.

Q15. Can fully licensed advanced practice providers (NPs and PAs) document supervision of students by attesting to the students' notes (as opposed to re-documenting the encounter) using a phrase like: "I was present with the student during the entire history taking and exam of the patient. I discussed the history, physical, pertinent studies, and medical management with the student. I have reviewed the student's note for accuracy and agree with the findings and plan as documented in the students note." and still bill for their services?
A15. Yes. As long as the student is eligible (not a college undergraduate), then CMS Change Request (CR) 11862 allows all physicians, Physician Assistants (PAs), Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), Certified Nurse Midwives (CNMs) and Certified Registered Nurse Anesthetists (CRNAs), recognized as Advanced Practice Registered Nurses (APRNs), to review and verify (sign and date) documentation in medical records without having to re-document notes already included in the medical record. However, mid-level providers (NPs and PAs) cannot supervise residents.

Q16. When a controlled substance is administered during an emergency room visit, would the medication always be considered high risk under the management options?
A16. The answer depends on the situation. There isn't an "always" answer when determining the risk management of a patient. The documentation would determine the work involved by the billing provider in managing the patient's risk, the involvement of the controlled substance, and the intensive drug monitoring for toxicity. When providing an injection for pain, is it intra-muscular (IM) or subcutaneous (sub-Q)? What other conditions or comorbidities does the patient have, and age may have a factor when managing for toxicity.

Q17. If a patient has Diabetic Sensory Neuropathy with Loss of Protective Sensation (LOPS), do we also need to include one of the Class A, B, or C modifiers Q7, Q8 or Q9? NCD 70.2.1 shows this diagnosis with an asterisk.
A17. Yes. When the patient's condition is one of those designated by an asterisk (*), routine procedures are covered only if the patient is under the active care of a Doctor of Medicine or Osteopathy, who documents the condition. Modifier Q7, Q8, or Q9 are required to indicate the documentation supports a necessary and integral part of foot care that meets the exceptions of routine foot care. NCD 290.2 supersedes the LCD and/or LCA and the provider must document sufficiently to demonstrate medical necessity which includes the Class findings.

The provider must also clearly indicate why the callous(es) required debridement, including the Class A, B and/or C that the provider has noted the presence of such findings, how these findings integrate into the foot care of the beneficiary, and documented within the medical record. The paring of a callus is not reasonable; however, the presence of a callous must indicate repetitive trauma to the area with a systemic condition diagnosis. Noridian expects the record to reflect what measures are taken to prevent recurrence; in particular, how the footwear is or was being modified. Review the CMS IOM Publication 100-02, Chapter 15, Section 290 - Foot Care.

Q18. When do providers refer to the Local Coverage Article (LCA), Billing and Coding to indicate treatment of painful calluses?
A18. Refer to your jurisdiction LCA for Routine Foot Care that provides billing and coding guidance, when paring or cutting of benign hyperkeratotic lesion(s); e.g., corn or callus.

Q19. Do we know when the COVID-19 Public Health Emergency (PHE) waivers will end?
A19. No. The Department of Health and Human Services (HHS) has stated they will provide 60-day notice prior to the PHE termination. More information can be found at the HHS.gov under Administration for Strategic Preparedness and Response (ASPR) website.

VERBAL Q/A DURING ACT:

Q20. Are the Wound Care LCDs and LCAs still active?
A20. Yes. There is Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services, Wound and Ulcer Care, and Routine Foot Care articles. Some LCDs have more than one LCA. There are a small number of CPTs that can be used for different conditions (wound care vs. debridement), which may be found in the LCDs and LCAs.

Q21. Is ICD-10 diagnosis D48.5 (Neoplasm of uncertain behavior of skin) used when pathology cannot determine if the lesion is malignant or benign? If the provider is unsure of whether the skin lesion is benign or malignant and submits to pathology, should we bill ICD-10 D49.2 (Neoplasm of unspecified behavior of bone, soft tissue, and skin), because this code includes Neoplasm, not otherwise specified (NOS)?
A21. Yes. If the provider is unsure of whether the skin lesion is benign or malignant and submits to pathology, the provider should use diagnosis D49.2.

Q22. In terms of benign lesion destruction codes, can providers not submit a claim to Medicare? Is there any regulation stating a healthcare facility cannot offer a discount or reduced rate for a non-medically necessary procedure?
A22. Review the coverage conditions and make sure the service has never been covered by Medicare. Please speak with a healthcare attorney and make sure it doesn't fall within anti-kickback or similar laws. You could send a request to the Health and Human Services (HHS)-Office of Inspector General (OIG) for an opinion on your unique circumstances. Be careful as the procedure cannot be an inducement for other disallowed behavior. If the beneficiary requests to have Medicare billed, even for statutorily excluded services, providers must bill on their behalf.

Q23. Under Routine Foot Care article, it looks as though CPT 11720 and 11721 have been modified for what is medically necessary based on billing denials. When looking at the material, I'm not seeing requirements for the pain code section (pain of foot, pain of toes), and appears it needs to be included on the claim. Primary and secondary diagnosis requirements had been billed. Was there an article change recently? Please confirm about the use of the Q modifier not included on Group 1 or 2 pairing?
A23. Providers must have two diagnoses (appropriate primary and secondary) from the article. The updated article only had changes to the phrasing and layout and the tables were clarified for easier reading. These services can be billed with a primary from group 1, and then a diagnosis from group 2 or 4. If billed with a Q modifier, they must have a primary diagnosis from group 1 and secondary diagnosis from group 3 only.

CPTs 11720 and 11721 have additional, unique diagnosis criteria and can be billed in three approaches with the third option including a primary diagnosis in group 5 with a secondary diagnosis from group 6. Again, this was not a change in policy as the grouping had differed and broken down for easier reading. The primary and secondary need to be from the appropriate groups. Q modifier is specifically for secondary diagnosis code from group 3. Do not bill a Q modifier if diagnoses are from Group 1 and 2 together or from Group 1 and 4 together. Review the Billing and Coding: Routine Foot Care - Local Coverage Article (LCA) A57954.

Q24. For teaching students and supervision, does this include residents or teacher students? We have students in family medical offices acquiring residency. Can we have our NP and PA sign off for them?
A24. No. Physician Assistants (PAs) and Nurse Practitioners (NPs) training does not contain the same elements as that of a physician, and neither does the scope of practice, which for both includes supervision or delegation by a physician. If you are speaking of medical students, the answer is still no, as their supervision is by the Medical School physician staff. It is possible that a NPP could observe while a medical student performs some part, but there would still need to be a qualified Physician teaching the event for those medical students. Residents are licensed or eligible, so their scope of practice supersedes that of NPPs.

Noridian would ask if the resident's criteria was satisfied and what type of student they are supervising. Review the CMS Medicare Learning Network (MLN) Teaching Physicians, Interns, & Residents Guidelines Fact Sheet, pages 4, 5, and 6. These requirements must be met:

• The services are identifiable physician services, the nature of which require performance by a physician in person and contribute to the diagnosis or treatment of the patient's condition and
• The intern or resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the State where the services are performed

Students Providing Evaluation & Management Documentation

• Students taking part in and contributing to a billable service must perform in the physician's or resident's physical presence, and meet teaching physician billing conditions. E/M services include separately billable services, except systems review and/or past family and social history.
• Students may document services in the patient medical records. Teaching physicians must verify all student medical record documentation or findings, including history, physical exam, and medical decision-making.
• Teaching physicians must personally perform (or re-do) all billed physical exam and medical E/M decision-making services. They can verify any student documentation in the medical record rather than re-documenting.
• CMS Teaching Physicians, Interns and Residents Guidelines Booklet - May2022

Q25. When billing for an Evaluation and Management (E/M), do multiple (two or more) acute, uncomplicated illnesses or injuries make a moderate Number and Complexity of Problems Addressed?
A25. The answer depends on the situation. When you look in the AMA CPT book, it indicates under Table 2: Levels of Medical Decision-Making (MDM); based on 2 out of 3 elements. Moderate complexity of problems during the encounter include:

• One or more chronic illnesses with exacerbation, progression, or side effects of treatment OR
• Two or more stable, chronic illnesses OR
• One undiagnosed new problem with uncertain prognosis OR
• One acute, complicated injury

The CPT book also shows Amount and/or Complexity of Data to be Reviewed and Analyzed for moderate level of medical decision-making (MDM).

Q26. Can you clarify pathology billing of 76098 (radiological exam, surgical specimen) and is it appropriate for a pathologist to bill a second film for the purpose of pathology evaluation separate from the intraoperative session?
A26. No. Medicare does not generally allow two physicians to read and interpret a film or specimen, so you may not receive payment if the radiologist has previously submitted a claim for the same service. Since the pathologist is not the radiologist performing the exam and is evaluating the report, modifier 26 should be appended to 76098. If the claim denies, because the CPT was "paid to another provider," you could appeal with modifier 77 (repeat by another physician). Noridian recommends checking with your national association "American Society for Clinical Pathology (ASCP)" for additional guidance.

Q27. When performing two diagnostic procedures (i.e., colonoscopy and Esophagogastroduodenoscopy-EGD) with modifier 51), should moderate sedation be billed for both procedures? Should we bill G0500 for the first 15 minutes on the same claim, as long as the diagnosis pointers are correct? Should the units for sedation be added together as 2 units? Would the same answers be true for a diagnostic and screening colonoscopy procedure on the same day? How should we bill for a single procedure that takes longer than 15 minutes?
A27. Medicare allows separate reporting for moderate conscious sedation services (CPT codes 99151-99153) when provided by the same physician performing a medical or surgical procedure, except when the anesthesia service is bundled into the procedure (e.g., radiation treatment management). For example, CPT 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression [separate procedure]) and CPT 43235 (EGD) billed with the HCPCS G0500 ((moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; patient aged 5 years or older; first 15 mins.) can be billed. CPT 99153 (moderate sedation; each additional 15 minutes of intra-service time) may be reported for additional time as appropriate.

For the endoscopy or GI CPT codes, HCPCS G0500 would need to be appropriate for the situation and providers involved. These are no longer bundled and place of service (POS) 22 is also allowed if the physician directly supervises the RN. G0500 can be used with several endoscopy codes (43xxx, 453xx series, G0105, and G0121).

A physician must continuously be present to monitor and personally provide care to patients. The presence of an underlying condition alone, as reported by an ICD-10-CM code, may not be sufficient evidence that Moderate Sedation is necessary. The medical condition must be significant enough to impact the need to provide Moderate Sedation. The presence of a stable, treated condition of itself is not necessarily sufficient. Change Request (CR) 10075 discusses the CMS Payment for Moderate Sedation Services Furnished with Colorectal Cancer Screening Tests and states Medicare shall not apply deductible and coinsurance to claim lines with HCPCS codes G0500 or 99153 when submitted with the PT modifier.

Note: MPPR rules do apply allowing at 50% of practice expense. In the case of multiple unrelated endoscopies (e.g., 45xxx series), watch the allowance reduced based on the "family base procedure code". More information is available in the CMS IOM Publication 100-04, Chapter 12, 100.1.2.5.