Article Detail - JE Part A
ACM Questions and Answers - August 28, 2024
Written Questions
Q1. CPT code 0499T (Cystourethroscopy, with mechanical dilation and urethral therapeutic drug delivery for urethral stricture or stenosis, including fluoroscopy, when performed) was changed to new code 52284 (Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis, male, including fluoroscopy, when performed) as of January 1, 2024. Is this new code, 52284, considered investigational?
A1. The American Medical Association's (AMA's) new code 52284 was implemented in 2024 as a Category I code. As a Category I code, 52284 satisfies additional AMA criteria over the Category III. However, the AMA's assignment of Category I coding, does not affect CMS' nor a Medicare Administrative Contractor's (MAC's) determination as to the investigational or experimental nature of a service, nor does it determine coverage and payment.
Q2. Can a Rural Health Clinic (RHC) perform annual wellness visits via a telephone encounter?
A2. Through December 31, 2024, all providers who are eligible to bill Medicare for professional services, including RHCs, can provide distant site telehealth.
Practitioners can provide telehealth from any distant site location, including their home, during the time they're working for the RHC, and they can provide any distant site-approved telehealth under the Physician Fee Schedule (PFS). You can't bill the visit's cost or include it on the cost report. Note: Section 4113 of the CAA 2023 extends the telehealth policies enacted in the CAA 2022 through December 31, 2024.
Q3. Do we need to do a refund before rebilling with corrected charges? What are the parameters to send a corrected claim if we do it in Direct Data Entry (DDE)? How do we do it to have it proceed rather than be rejected?
A3. In some cases, you do not have to initiate a refund. In the Direct Data Entry (DDE) system, you can submit an adjusted claim using Type of Bill XX7, which in this example, would allow you to make a correction to the billed amount(s). If you are correcting to lessen charges on an already-paid line or claim, the system is able to initiate a partial takeback on an amount that had already been paid without new claim action initiated by you. Make sure that you utilize the correct Condition Codes during this process, as they indicate the reason for the change on the paid claim. Our Condition Codes page is located within the Quick Reference Billing Guide on the Noridian website. (Note, medically denied claims or lines can't be adjusted with this process. They must go through the Appeals process.) Noridian does have tutorials and the DDE User Manual available online for the DDE claim adjustment process.
Q4. What are the guidelines billing an emergency room (ER) visit or office visit 72 hours before inpatient stays? Is it included on the inpatient claim? Do we need to add a modifier? Does it have to be related to the inpatient stay?
A4. Medicare's three-day (or one-day) payment window applies to outpatient services that hospitals and hospital wholly-owned or wholly-operated Part B entities furnish to Medicare beneficiaries. Any item or service that is related to the upcoming inpatient stay, including the ER or office visit you mention, will be bundled into the inpatient bill. Using a modifier on the code would not specifically make this correlation. CMS does publish a lot of information on the 3-day (and 1-day) pre-admission windows. A great resource for this topic is MLN Matters SE20024.
Q5. Are providers allowed to apply intent-to-order when an inpatient or observation order is missing or ambiguous? It is my understanding that only the MAC may utilize intent-to-order guidance for inpatient orders and intent-to-order does not apply to observation orders.
A5. According to 42 CFR 412.3, an inpatient admission order must be in the medical record for payment. If the order is unclear, but the intent to admit as an inpatient is evident and shown as medically necessary, then it could be considered acceptable. The same principle would apply for the intent to "admit to observation."
These conclusions will align with the admitting physician's documentation. In such situations, hospitals should include a separate attestation, with the admitting physician documenting why inpatient (or observation) care is required. Medical records must support coverage criteria (including medical necessity) and meet Medicare's Conditions of Participation. The order must be authenticated before discharge or billing Medicare.
Q6. On April 25, 2024, you published the Billing and Coding: Cryoneurolysis Instructions article (A59752/A59753) in the CMS Medicare Coverage Database, but it was not included on your website, so we had to use Google to find it. Our question pertains to code 0441T. CPT Assistant from April 2019, page 9, states that this code is used ablation and that cryoneurolysis is reported with codes 64640 or 64624. Was there a reason this instruction was not included on your website? We want to clarify which code should be used for cryoneurolysis. Please clarify if the instructions are current and how they should be followed.
A6. While the Billing and Coding: Cryoneurolysis Instructions article was posted to the Medicare Coverage Database (MCD), we missed adding it to the Noridian Billing and Coding Articles webpages. We apologize for the error and can confirm this has been added as of August 27, 2024.
Noridian guidance indicates CPT 64640 and 64624 require the destruction of target nerve(s). Noridian would look to using 0440T, 0441T, or 0442T, depending on the location, for Cryoneurolysis when billing Medicare until a permanent CPT is provided.
Q7. Can the hospital bill a G0463 (hospital outpatient clinic visit for assessment and management of a patient) for an in-person, medically necessary medication management service provided by a pharmacist that is within scope and state of Montana licensure?
A7. Yes, the hospital may use this code in the billing of that service. It represents the hospital's resources (overhead expenses) used for the clinic visit. Making sure that the service is within state scope of practice and aligns with your hospital's best practice.
Q8. Can you please explain how to properly build G codes with $0.00 charge? I have claims that will not go through to Medicare and so we need to add a G code and then the claim returns to provider (RTPs) in the Common Working File (CWF) for a G code with $0.00 charge.
A8. We do hear of this issue from time to time. Some billing software programs don't always like zero-dollar values in the Amount fields. In these cases, we usually advise to try billing the line for a nominal charge ($0.01) to allow the claim to pass by those types of edits.
Q9. Regarding imaging orders, if the treating physician orders a 2-Views Chest X-ray, and a 3-Views Chest X-ray is instead performed or if a 2-view chest x-ray is ordered and a single-view chest x-ray is performed by the radiology technician, would a new order be required, or is documentation by the radiologist as to why the procedure was not fully performed sufficient?
A9. Yes, a new order should be written, and it should also be documented in the medical record the reason for the change in order. For services performed in a hospital, the CMS Conditions of Participation: Radiology Service Rules (42 CFR 482.26) apply. These rules state that "Radiologic services must be provided only on the order of practitioners with clinical privileges or, consistent with state law, of other practitioners authorized by the medical staff and the governing body to order the services." Since radiologists generally meet these qualifications, no effort has been made to exclude them from rights and privileges granted others.
The radiology report should explain the reason for change in order and the revised order must be authorized by ordering physician or by the hospital's governing body, can be authorized by radiologist. The key to this would be communication with the ordering provider and an updated order.
Q10. What date is populated for occurrence code 29? The date the therapist evaluated the patient and created the plan of care OR the date the ordering provider (MD, ARNP, etc.) signed and certified the plan of care? The UB Editor, Claims Processing Manual, and all guidance we can find simply say "Date Outpatient Physical Therapy Plan Established or Last Reviewed." This is a poorly defined occurrence code as the term "reviewed" does not translate to therapist evaluation date or ordering provider certification date.
A10. The provider has the option to use the date the therapist evaluates patient and creates the plan of care (POC) or the date the ordering provider reviewed/signed and certified POC. CMS does not elaborate on the who does the reviewing, however for a physician or nonphysician practitioner (NPP) to certify a POC, they would certainly need to review it first.
An exception is for Comprehensive Outpatient Rehabilitation Facility (CORF). (CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.1.2.A. - Establishing the plan). Only a physician may establish a plan of care in a CORF.
Q11. Regarding the delivery of the Medicare Important Message (IM), in the Medical Claims Processing Manual, Chapter 30, Section 200.3.3, it states the beneficiary must be given the option of requesting paper issuance over electronic issuance if that is what the beneficiary prefers. However, the next sentence then states, "Regardless of whether a paper or electronic version is issued and regardless of whether the signature is digitally captured or manually penned, the beneficiary must be given a paper copy of the IM."
Does the beneficiary have a choice of paper or electronic issuance, if it states a paper copy of the IM must be given? Note: The verbiage in Section 200.3.3 also states "…as specified in 200.3.9," however, there is no Section 200.3.9.
A11. Yes, a paper copy of the Medicare Important Message (IM) needs to be given to beneficiary. They do have a choice on how to read the IM, either electronically or by paper, but the beneficiary must receive a paper copy of notice so that they always have access to it.
Q12. Some of our mental health providers are MDs. They submit evaluation and management (E&M) codes for behavioral health services when there are medical and mental health visits on the same day, both reported with E&M codes. How do we submit them both on the claim? Can the mental health visit be submitted with Revenue Code 0900?
A12. Yes, qualified mental health visits billed under revenue code 0900 receive an additional payment when billed on the same day as a medical visit (051X or 052X). Revenue code 0900 is used to report certain behavioral health, psychiatric, and psychological treatment and services.
Verbal Questions
Q13. Regarding cardiac rehabilitation program, is there a time limit between when the evaluation is completed and when the first treatment session is performed?
A13. There is not a set timeline between the evaluation and the initiation of cardiac rehabilitation. There are recommendations for certain events, but there are not set guidelines.
Q14. Regarding cardiac rehabilitation program, do the treatment sessions need to be completed within one year of the qualifying event or the when the condition happened that qualified them for the cardiac program?
A14. The order for treatment sessions is only good for one year. Sessions would need to be completed within that timeframe.
Q15. If a patient came into the emergency department one night with a Medicare Advantage (MA) plan, and then the next day or two days later, became Fee-for-Service (FFS) Medicare-eligible, who should the claim be billed to? Is it based on the admit order?
A15. In the case of Inpatient Prospective Payment System (IPPS), the CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 90, outlines that it is based on the admission: "If the provider is an inpatient acute care hospital, inpatient rehabilitation facility or a long term care hospital, and the patient changes MA status during an inpatient stay for an inpatient institution, the patient's status at admission or start of care determines liability."
