Article Detail - JE Part A
ACM Part A Questions and Answers - August 30, 2023
Q1: We recently had a denial on a CT Low Dose Lung Screening due to frequency as patient had had another one within the previous 12 months. Why is this information not available on the Noridian Medicare Portal if you expect providers to track, as nurses do not have time to call the customer service line to determine this information?
A1: HCPCS code 71271 is one of the codes that HETS will provide as a Preventive Service on the Portal. Additionally, first the patient will need to have the initial lung cancer screening visit (HCPCS G0296) before they are eligible for the actual CT scan (CPT 71271). If the patient hasn't had their initial visit yet, then the CT scan information would not display. HETS stands for the HIPAA Eligibility Transaction System.
Q2: How far in advance can we do the MSP questionnaire when we pre-register patients before their scheduled appointment or test?
A2: CMS does not state a firm window on this parameter in its materials. CMS only states that the billing information must be collected prior to providing hospital services. For recurring services following the initial collection, it should be verified once every 90 days. Note that a Medicare beneficiary is considered receiving recurring services if he or she receives identical services and treatments as an outpatient more than once within a billing cycle.
CMS MLN006903 - Medicare Secondary Payer Fact Sheet
Q3: When this program first started, it was discussed that you could appeal on the back end for medical necessity if a Prior Authorization was not obtained. We have tried unsuccessfully to appeal cases for no prior authorization for review for medical necessity and Noridian/Maxim continue to deny for no prior auth, never reviewing for medical necessity. Even though we feel medical necessity was met. Are you saying that if a prior auth was missed for a certain procedure there is no recourse to appeal?
A3: CMS addressed this in Question 28 of a Prior Authorization FAQ document that was most recently updated in April 2023. "Failure to submit a prior authorization request for a service on the prior authorization list will result in the denial of the service. These denials are considered initial determinations that are subject to appeal. In processing an appeal of a claim for which there was no submission of a prior authorization request, MACs will acknowledge the issues raised by a party in the redetermination notice. MACs will consider whether there was, in fact, a prior authorization request submitted for the OPD service as required in regulation. If no prior authorization request was submitted, payment shall not be made due to the failure to comply with a mandatory condition of payment, even if the item or service is otherwise covered."
Q4: Will Appropriate Use Criteria go into effect as planned on January 1, 2024? Or will it be delayed?
A4: CMS has published two notices on this. The payment penalty phase will not begin January 1, 2023, even if the PHE for COVID-19 ends in 2022. Until further notice, the educational and operations testing period will continue. CMS is unable to forecast when the payment penalty phase will begin. All CDSMs and PLEs qualified as of July 2022 will remain qualified through this cycle. Applications for initial qualification or re-qualification will not be accepted for the 2023 application cycle.
Questions regarding this program may be submitted to the CMS Imaging AUC resource box: ImagingAUC@cms.hhs.gov
Appropriate Use Criteria Program | CMS
Q5: What is the appropriate way to bill COVID-19 vaccines given by hospital staff within the 3-day payment window of an inpatient stay? We understand that it may be billed separately and receive separate reimbursement even if it was combined with the IP claim.
A5: There are two scenarios to be considered:
- Related to inpatient admission: If the outpatient non-diagnostic service (the COVID-19 vaccine) is clinically associated with the reason for inpatient admission, then it is subject to bundling, and the non-diagnostic service is reported on an inpatient claim (TOB 11X) with the appropriate condition code A6 and diagnosis code Z23.
- Unrelated to inpatient admission: If the hospital determines the non-diagnostic preadmission service is NOT clinically related to the inpatient admission, then it is NOT subject to the 3-day payment window policy. Hence, the hospital must bill on an outpatient claim TOB 13X, with condition code 51 (as an attestation of unrelated OP non-diagnostic service).
Be sure that Inpatient 11X TOB is finalized first, prior to submitting another claim (12X TOB).
Q6: There was a new IOCE edit implemented 4/1/23 when IMRT planning codes were billed on the same claim with IMRT code 77301. In the past we have been able to bill for these services if there were extenuating circumstances during treatment which required additional workup as long as these other services were not provided as a part of the initial IMRT planning. We would report these additional services with a 59 modifier, typically receive a denial, and would appeal these with documentation supporting the medical necessity of the services. These claims now RTP and we cannot bypass the RTP, even with adding a modifier. Is it CMS's intention that these additional services outside of the initial IMRT planning will no longer be reportable?
A6: Payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). These codes should not be reported in addition to CPT code 77301 when provided prior to or as part of the development of the IMRT plan. Accordingly, modifier 59 should not be reported with these codes. For additional billing information on IMRT planning codes, please consult the following Noridian and CMS resources:
Intensity Modulated Radiation Therapy (IMRT) Billing
CMS SE 18013 - Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing
Q7: Can you please clarify how Medicare defines the word "related" in the 3-day window rule. Is it that the diagnosis of the outpatient visit is required to match exactly the inpatient diagnosis?
A7: No. A service may be clinically related to inpatient admission "regardless of whether the inpatient and outpatient diagnoses are the same." The 3-day (1-day) payment policy applies to all non-diagnostic services provided during the payment window unless the hospital attests that services are clinically unrelated. Diagnostic services are always subject to the payment window, irrespective of whether they are considered clinically related. Refer to Frequently Asked Questions CMS Change Request (CR) 7502.
Q8: How do I bill items which go over the MUE and still reflect exactly the services which were provided?
Example 1: The MUE for a low osmolar contrast is 300; however, there are times when the calculation of the dosage is 310. Does Noridian expect to see a unit of 300 (the maximum MUE unit) or 310 (the actual units given)?
Example 2: The MUE for EKG is 5; however, there are times when it is clinically necessary to exceed this. So, if 7 EKGs are performed on a single date of service, does Noridian expect to see a unit of 5 (Maximum MUE) or 7 (the actual services provided)?
A8: This depends on the MUE Adjudication Indicator (MAI). MAI 1 indicates a value adjudicated by claims processing systems at the claim-line level. When reported on separate lines, the CPT requires modifiers 76 or 77 to distinguish repeated services. MAI 2 is an absolute date of service edit based on policy, such as anatomic considerations, definition of the code, or published CMS policy. MAI 3 indicates a value adjudicated by claims processing systems at the date-of-service level. If these claim denials are appealed, MACs may pay the units of service above the MUE value if adequate documentation exists of the medical necessity of correctly reported units.
The MLN Educational Tool, How to Use the Medicare National Correct Coding Initiative (NCCI) Tools, provides more information.
Q9: I have a question on what the contractor considers a "chemo" administration versus a "therapeutic" administration. There are many drugs which are used as an antineoplastic; however, are not considered a chemo drug. An example of this would be Leucovorin. It is sometimes a chemo and sometimes not. Other examples would be some antibiotics and monoclonal antibodies. Is there a list of drugs considered to be chemo?
A9: CMS details these drugs in CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners, Section 30.5. Noridian, for its part, uses the chemotherapy description in the CPT manual. Chemotherapy administration codes apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also, to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers. The following drugs are commonly considered to fall under the category of monoclonal antibodies: infliximab, rituximab, alemtuzumab, gemtuzumab, and trastuzumab. Drugs commonly considered to fall under the category of hormonal antineoplastics include leuprolide acetate and goserelin acetate. This is not a complete list of drugs that may be administered using the chemotherapy administration codes. The administration of anti-anemia drugs and anti-emetic drugs by injection or infusion for cancer patients is not considered chemotherapy administration.
Q10: My question is when an infusion should be billed as a concurrent infusion: CPT code 96368. The CPT code 96368 for concurrent infusion is not a timed code, but many times there is an overlap of time between drugs given on the same date of service. This is time overlap can be a small one of just a minute to 15 minutes or more. This time overlap can be due to the nurse administering the medication stopping the infusion pump and getting the other med set up, an IV bag having slight overfill from the pharmacy, etc. This is where we have a bit of a struggle to determine whether a drug should be a concurrent infusion. Since it is not a time-based code, could it mean any overlap of time to the primary drug being infused means that the 2nd drug is concurrent?
A10: Concurrent infusion is when multiple therapeutic or diagnostic medications are infused simultaneously through separate bags through the same IV line. Assuming the administration of each bag meets the requirements for reporting an infusion. The assertion that CPT 96368 is not time-based is correct, and it can only be reported once per encounter.
Medicare NCCI 2022 Coding Policy Manual - Chapter 11 CPT Codes 90000-99999
Q11: Regarding the delivery of the Important Message from Medicare (IM), the Medicare Claims Processing Manual, Section 200.3.7 provides examples of representatives, including appointed, authorized, or a person whom the hospital has determined could reasonably represent the beneficiary if the beneficiary is temporarily incapacitated. In a situation where an incapacitated beneficiary has absolutely no identifiable representatives or other persons who can represent the beneficiary, how would the delivery of the IM be conducted or documented to be compliant?
A11: For patients who are temporarily or permanently incompetent, hospitals must provide notice to an authorized representative or a person the hospital has determined could reasonably represent the beneficiary, and acts in their best interests, in a manner protective of the beneficiary's rights and who has no conflict of interest. When delivering the IM notice, document the details in the "Additional Information" section of the IM form. Document the name of the staff person initiating the contact; the name of the person contacted; and the date, time and method of contact (e.g., in person or by telephone).
Q12: Regarding the delivery of the IM, if an inpatient beneficiary is no longer acute level of care (i.e., drop down to Skilled Nursing (SNF) or Intermediate Care/Custodial Nursing (NF/ICF) level of care), would a SNF and/or NF/ICF level of care be considered a "discharge," thus requiring the follow-up IM to be delivered? If so, how can the follow-up IM be delivered in a compliant manner when the level of care is changed retroactively by the Medicare contractor (i.e., Noridian)?
A12: Hospitals are required to deliver the IM at or near admission to all beneficiaries and enrollees with a copy at or near discharge except in short-stay situations. For purposes of this rule, and consistent with the revised definition of discharge at CFR §?405.1205 and §?422.620, any patient who is formally released from a hospital, whether that patient is going to another inpatient hospital, to a lower level of care such as a SNF (even a swing bed within the hospital), or to home, is considered discharged from that hospital.
Q13: Our claim is rejecting for the provider. If the address in PECOS doesn't match the address on the claim, will that cause the rejection? We have quite a few claims rejecting with the 34963 code due to the PECOS 2.0 update.
A13: No, the matching address for the rendered service in an off-campus, outpatient department of a hospital is verified with the PECOS file address using edit 34977. For the edit 34963, providers should review MLN Matters (MM) 12889 to verify what professionals are eligible as an attending physician. They should also verify that those professionals are currently enrolled with Medicare under the specialty that is being billed. Providers should review CMS SE 18002 - Billing Requirements for OPPS Providers with Multiple Service Locations for both enrolling off campus providers AND the table starting on Page 4 outlining WHEN it is and is not appropriate to report a service facility address and if it is or is not appropriate to report a PO or PN modifier. PECOS 2.0 is not live yet. It is tentatively scheduled to go live later this fall.
Q14: Is it appropriate to bill Noridian for services that are statutorily excluded that have an E1 status indicator? If it is appropriate, do we bill with the GY modifier in the non-covered field? Will Noridian process this as patient responsibility or a denial to our facility?
A14: E1 is an OPPS status indicator. Items, codes, and services not covered by any Medicare outpatient benefit category; statutorily excluded; not reasonable and necessary. Not paid by Medicare when submitted on outpatient claims (any outpatient bill type). Yes, it would be appropriate to bill the services as non-covered and therefore receive a denial from Medicare. Appending modifier GY indicates "Notice of Liability Not Issued, Not Required Under Payer Policy" and would cause the claim line to deny with the patient liable for charges.
Notification Requirements for Noncovered Charges
Q15: We are looking to see if it's possible to bill chemo as recurring accounts and if so, assuming that the OPPS charges that are paid on an APC, if we have charges on the same day, they would be complying to the chemotherapy if that would be allowed?
A15: The IOM 100-04, Chapter 1, Section 50.2.2 outlines the services CMS considers repetitive. Repetitive services (therapy revenue codes) can have a carve-out period as appropriate. Recurring charges such as chemotherapy, billed in conjunction would need to be combined and not carved out.
Q16: Is it OK to bill chemotherapy as a recurring account?
A16: Yes. The thing to be careful with is other outpatient hospital claims being billed on the same day.
Q17: Regarding the modifier JZ, can we use a single dose vial on multiple patients? How does that impact the usage of modifier JZ? For example, if the single dose vial is used between three patients with no wastage, how would we report the claim for each patient? We found a regulation from CMS from June 2012 that says facilities can use sufficient use of drugs available. Reuse must be compliant with infection control policy.
A17: In the CMS Memo #12-35-ALL titled "Safe use of Singe Dose/Single Use Medications to Prevent Healthcare-associated Infections" posted on 6-15-2012, CMS states that they are "equally concerned about healthcare-associated infections caused by unsafe medication preparation and injection practices, including using SDVs (single dose vials) for multiple patients in the same manner as vials labeled as multi-dose. Such reuse of SDVs is not compliant with infection control requirements and must be cited as a deficiency. We are not changing our policy on this matter."
We have addressed this in our Local Coverage Article A53024 in Item 3: Any amount of drug billed as wastage from a single-dose vial, must be discarded and may not be used for another patient regardless of whether that other patient has Medicare.
The JW and JZ modifier only apply to drugs/biologicals in a single-use vial or other single-use packaging.
Billing and Coding: JW and JZ Modifier Billing (A53024)
Q18: Regarding the earlier question about the IM, if there is no identifiable representative for the beneficiary, we must document that. If we can't identify anyone, who would we document?
A18: If there's no one available, you would have another staff member verify and document that there was no other identifiable representative. Document these details in the "Additional Information" section of the IM form.
Q19: We have several claims in RTP for provider-based facilities. I'm sure it's probably related to PECOS. We did search the Special Edition article that went out. We provide all the service locations for the onsite campus.
A19: Providers are getting confused on two separate Special Editions. The main one you'll want to review is CMS SE 18002, Billing Requirements for OPP Providers with Multiple Service Locations, starting on Page 4. It goes over starting with different billing scenarios. It outlines the service facility address requirements. Starting with the table, "Main Campus-only" example: if all services are provided on the main campus, you will provide the billing address and not the service facility or off campus location. It depends on if any services were provided at an off-campus location. Providers are required to report any off-campus locations and enroll them in PECOS to ensure all off-campus locations were submitted in the file appropriately before turning off edits. You may have several addresses. If a patient goes to your main campus, after they've received something such as labs at a different location and use the appropriate modifiers and off campus address.
Q20: I have a follow up question regarding the delivery of the IM. I want to clarify, what if the level of care was determined after the patient was discharged? If it was retroactively changed. For example, the patient was still in house on Day 25 but during peer review they should have stepped down on Day 20, so they drop down the charges, but the IM did not happen because they were still in on Day 25, but it was Day 20 that the patient technically stepped down to that level of care.
A20: That requires a HINN. If no HINN was issued it is provider liable. The IM is given right away once you realize that the patient no longer qualifies for the inpatient stay.
Q21: I have follow-up on the concurrent infusion question. When two drugs end up being infused for about 2-15 minutes (together), is the second drug concurrent or subsequent infusion? How do you want to see that? Drug 1 is infused for an hour. Drug 2 gets started 5 minutes before Drug 1 is finished. The drugs are on the same access line. Is that subsequent or concurrent?
A21: Concurrent is when multiple therapeutic or diagnostic medications are infused simultaneously through separate bags through the same IV line (same access line). So it is concurrent, even if it's just five minutes of overlap.
Q22: We have a patient who has Part A and not Part B, and their claims keep getting denied by their other insurance saying they have Part B. The patient has called repeatedly and tried to work with the other payer, and I know that there's possibly a way to have the Common Working File verified. Is there someone I can contact or give them information to contact?
A22: The patient themself can call 1-800-MEDI-CARE. For you as a provider, any system that uses HETS, the HIPAA Eligibility Transaction System (including the IVR or NMP), if you're enrolled, you can utilize those tools to verify their eligibility.
