Article Detail - JE Part A

Written Questions

Q1: Local Coverage Article (LCA) A52950 retired effective 11/01/23, does Noridian still have a system edit in place that will reject claims if providers do not enter the device manufacturer for C2616 (Brachytherapy)? Previously, when billing HCPC C2616, Noridian would reject claims if providers did not enter a remark/note with the device name of either TheraSphere, or Sir-Spheres. Now that the LCA has been retired, can providers begin billing without the device name without the claim rejecting or denying?
A1: The system edits related to Local Coverage Article (LCA) A52950 were turned off at the same time as the policy was retired. Therefore, Noridian is no longer editing for these claims. While the policy is retired, we do still give the following guidance to providers, which is indicated in the Revision History:

Coverage articles may be retired due to lack of evidence of current problems or CMS may have issued guidance regarding national coverage. The Noridian guidance in the retired article may still be helpful in assessing medical necessity. Where providers have adjusted their billing and coding practices to correspond to the guidance in a coverage article, they will want to be careful in departing from these practices just because the article is retired. Provider offices remain responsible for correct performance, coding, billing, and medical necessity under Medicare. This responsibility for correct claims submission is unchanged whether or not there is a coverage article in place.

Q2: We are seeing an uptick of line-item drug denials on our CAH claims that we believe are associated with them lacking the JW or JZ modifier, however they are N-status drugs, meaning packaged and typically wouldn’t need the JW or JZ modifier because they are not separately payable. The two drugs we are seeing this on are J2795 and J9263. Noridian is not the only MAC we are seeing this on. We don’t have our JW or JZ modifiers set to be billed on drugs that are not separately payable, but we don’t see CMS guidance that indicates the rules around when to add these modifiers has changed. Thank you for any guidance you can provide!
A2: For the facilities paid under the Outpatient Prospective Payment System (OPPS), your statements would be correct. However, Critical Access Hospitals (CAHs) are not paid this way. CAHS are reimbursed separately based on reasonable cost for the services they provide, including these types of drugs. That means the Status Indicator of ‘N’ listed on the Addendum D1 will not apply for CAHs. So, in the end, these drugs are denying correctly for this CAH location for missing modifiers. Please see the current list of codes referenced below where the JW and JZ modifier policy applies, as well as Frequently Asked Question #6.

Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy HCPCS Codes (cms.gov)

Medicare Program Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy Frequently Asked Questions (cms.gov)

Q3: When a patient is an inpatient at IPF and pt’s Medicare status in ancillary (12xTOB), who do outside providers bill on consults or treatments? Who is responsible for ancillary co-pay, the IPF or the outside facility?
A3: The IPF is responsible for all services provided at other facilities during the inpatient stay. Federal regulations state that Medicare does not pay any provider other than the inpatient hospital for services provided to the beneficiary while the beneficiary is an inpatient of the hospital (42 CFR 412.50(b). This is detailed in CMS Medicare Learning Network (MLN) Matters Special Edition (SE)17033 - Medicare Does Not Pay Acute-Care Hospitals for Outpatient Services They Provide to Beneficiaries in a Covered Part A Stay at Other Facilities.

Acute-care hospitals, under arrangements with the LTCH, IRF, IPF, and/or CAH, should look to the LTCH, IRF, IPF, and/or CAH for payment for the outpatient services it provides to the beneficiary while an inpatient of that other facility. Additionally, acute care hospitals should not charge beneficiaries for outpatient deductibles and coinsurance payments due to such services.

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: If a patient were to fall in a hospital and the provider orders x-rays to check for fractures, I understand that CMS has a no-pay policy. Does that mean that I shouldn't bill the charge, or should I bill it and not expect to get paid?
A4: Any reimbursement for a billed service, including this example, could be reimbursed based on proper claim coding, documentation, and the medical necessity of the service provided. X-rays as a preventive service are not statutorily excluded from Medicare coverage. If your organization is billing for a service that is known to be statutorily excluded, or you know that it is not medically necessary, or you are billing to receive a Medicare denial, there may be specific coding requirements that will specifically assign the liability for the service either to the provider or the patient.

Q5: Can you please clarify what is the correct place of service (POS) for telehealth services performed when the provider is in a provider-based clinic, and the patient is in their home?
A5: Noridian has just updated its rolling slides for all presentations regarding this clarification. Starting January 1, 2024, use POS 02 for Telehealth to indicate you provided the billed service as a professional telehealth service, when the originating beneficiary site is other than the patient’s home – no modifier required. Use POS 10 for Telehealth for services when the patient is in their home – no modifier required. Exceptions: For outpatient therapy telehealth services by a PT, OT, or SLP, continue to bill with their actual POS (e.g., office 11), as if the patient was seen at their site and append the modifier 95 rather than a telehealth POS code. For outpatient hospital clinicians using either POS 22 (on-campus) or 19 (off-campus) for services when the patient is in their home, append modifier 95.

Q6: As a federally qualified health center (FQHC), is there a maximum-allowed limit of diagnoses that can be reported on the electronic format of the UB-04?
A6: This answer can be found in the Claims Processing Manual, Chapter 23, Section 10.3 - Outpatient Claim Diagnosis Reporting. For outpatient claims, providers report the full diagnosis codes for up to 24 other diagnoses that coexisted in addition to the diagnosis reported as the principal diagnosis. So, 25 in total. Additional information and training are available on the CMS website: https://www.cms.gov/medicare/coding-billing/icd-10-codes

Q7: When a patient is an inpatient at IPF and the patient’s Medicare status is ancillary (12x TOB), who do outside providers bill on consults or treatments? And who is responsible for ancillary co-pay, the IPF or the outside facility?
A7: The IPF is responsible for all services provided at other facilities during inpatient stay. Federal regulations state that Medicare does not pay any provider other than the inpatient hospital for services provided to the beneficiary while the beneficiary is an inpatient of the hospital (42 CFR 412.50(b). Per MLN SE17033, acute-care hospitals, under arrangements with the LTCH, IRF, IPF, or CAH, should look to the LTCH, IRF, IPF, or CAH for payment for the outpatient services it provides to the beneficiary while an inpatient of that other facility. Additionally, acute care hospitals should not charge beneficiaries for outpatient deductibles and coinsurance payments because of such services.

Q8: When a patient is ex parte (committed involuntarily), the IPF is financially obligated for said charges. How about when patient goes from ex parte to voluntary commitment?
A8: This is answered in the Internet-Only Manual, Publication 100-02, Benefit Policy Manual, Chapter 16, Section 50.3.3 - Examples of Application of Government Entity Exclusion. In general, payment may be made under Medicare for covered services furnished without charge by State or local psychiatric hospitals which serve the general community. (See §50.3.1.) However, payment may not be made for services furnished without charge to individuals who have been committed under a penal statute (e.g., defective delinquents, persons found not guilty by reason of insanity, and persons incompetent to stand trial). For Medicare purposes such individuals are "prisoners," as defined in subsection 3, and may have services paid by Medicare only under the exceptional circumstances described there. A psychiatric hospital to which patients convicted of crimes are committed is considered to be serving the general community if State law also provides for voluntary admissions to the institution.

Q9: Our facility is seeing total claim denials when G0260 is not billed with 77002 or 77012. CCI edit 3144 prevents us from adding the 59-modifier indicating that an add on code was reported without the appropriate base procedure. It does not seem correct to bill 77002 or 77012 in addition to G0260 when it goes against a CCI edit. Can we please have clarification on CMS guidance for the appropriate way to bill G0260?
A9: Per LCD - Sacroiliac Joint Injections and Procedures (L39462) (cms.gov) and Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59244) (cms.gov):

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 the ASC or OPPS hospital outpatient department for CPT codes 77002 and 77012.

Critical Access Hospitals (TOB 85X) should report sacroiliac joint injection with CPT 27096 and a sacral nerve block with CPT 64451. Bilateral injections should be reported using modifier 50. If a unilateral sacroiliac joint injection (CPT 27096) is performed and a unilateral sacral nerve block (CPT 64451) is performed on the contralateral side do not report modifier 50 with either code. Do not report a sacroiliac joint injection (CPT 27096) and a sacral nerve block (CPT 64451) for the same side, per the policy.

Q10: We are getting claims returned for Procedure to Device edits for Code C1761 – Catheter, transluminal intravascular lithotripsy, coronary when we bill 0715T – Percutaneous transluminal coronary lithotripsy (prior to 2024) and in 2024 code 92972 (same description as 0715T). HCPCS code C1761 became a transitional pass-through code in July 2021 (Transmittal 10825) with codes 92828 and C9600. In Transmittal 10997, code 92933, 92943, C9602 and C9607 were added to C9600 and 92928. Why do the claims not get paid with codes 0715T and 92972 when this coding guidance from the AMA? We have been told by the Provider Call Center that C1761 can only be paid with 92928 or C9600. Why does CMS not include 0715T and 92972 when that is the most appropriate procedure code? Can Noridian query CMS?
A10: According to CMS guidelines, the HCPCS code C1761, Coronary IVL device is used primary for endovascular procedures: C9600, 92928, 92943, or 92920. As described in the 2024 OPPS Final Rule, "only a small share of the PCI procedures uses the Coronary IVL device. Less than 6 percent of the procedures billed with HCPCS code C9600, CPT code 92928, and CPT code 92943 use the device described by HCPCS code C1761. For CPT code 92920, the percentage of procedures using the Coronary IVL device is less than 0.5 percent. The low amount of utilization of the Coronary IVL device with these PCI procedures means that it would not be appropriate to assign these procedures to a higher-paying APC to account for the cost of the device. These code combinations would also not meet the criteria for a complexity adjustment, as discussed in section II.A.2.b of this final rule with comment period. Likewise, we do not see a justification for extending device pass-through status for HCPCS code C1761."

Q11: Do you have examples of proper cardiac rehab documentation? We have received denials for no 'Outcome Assessment'. Our provider is providing goals/interventions and indicating if rehab should continue or be modified based on meeting or not meeting those goals but have been denied. Any guidance would be appreciated.
A11: Outcomes assessment means an evaluation of progress as it relates to the individual's rehabilitation which includes all of the following:

1. Evaluations, based on patient-centered outcomes, which must be measured by the physician or program staff at the beginning and end of the program. Evaluations measured by program staff must be considered by the physician in developing and/or reviewing individualized treatment plans.
2. Objective clinical measures of exercise performance and self-reported measures of exertion and behavior.

E.g., This refers to the need for the program to show the interventions or services did or did not result in some benefit to the patient. For example, if the goal was to lose one pound a week, there should be notation in the file of the beginning weight was 230 pounds and the weight after 4 weeks was 232 pounds, and the goal was not met. Or the goal was for the patient to be able to walk for 30 minutes on the treadmill at 2 miles per hour daily without chest pain or undue shortness of breath and the goal was met or not met. If the goal was not met, it is prudent to include what modifications were made to the care plan to address the failure. Like all such notes, it must be signed and dated by the person doing the assessment, with his or her credentials, on the day the assessment is done.

Q12: Can I get a breakdown of "spell of illness? If our IPF patient was discharged and readmitted, do I wait 60 days from admit and do the spell of illness all over again?
A12: "Spell of Illness," or benefit period, is a period of consecutive days during which medical benefits for covered services with certain maximum limitations, are available to beneficiary. The benefit period begins the day a beneficiary is admitted as an inpatient to a hospital or Skilled Nursing Facility (SNF) and ends when the beneficiary is not an inpatient of a hospital or SNF for 60 consecutive days. If a beneficiary is admitted as an inpatient after 60 consecutive days, a new benefit period will begin.

In answer to your second question… No, it would be 60 days from discharge. Under Part A, 60 full days of hospitalization plus 30 coinsurance days represent the maximum benefit period. The benefit period is renewed when the beneficiary has not been an inpatient of a hospital or of a SNF for 60 consecutive days. Refer to IOM Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3 for additional information on benefit periods.

Verbal Questions

Q13. We have a hospitalist no longer with our Critical Access Hospital facility. We have a couple of inpatient visits with missing progress notes for that provider. Can we bill out the whole visit minus that day with the missing progress note?
A13. Generally speaking, in a Medical Review situation, the medical records (progress notes) have to support the entire stay. However, it is an option for the facility to bill the 77 occurrence span code for a provider liable day.

Q14. We’re in the process of redoing these claims that are going to be denied timely that involve spell of illness. Do I still need to add those in since the patient was inpatient? Are the spell of illness days included in the timely claims?
A14. The Inpatient claims that fail to be billed timely still do need to be submitted. The Medicare Claims Processing Manual, Chapter 1, Section 70 outlines how to bill when you are past timely filing. Untimely claims will also update spell of illness on the national file, yes.

Q15. We have confusion on our IPF ancillary billing. If our patient goes to an outside consult, does that consultant bill Medicare under the Part B benefit, or do they bill us?
A15. The physician will bill Medicare through the hospital on the 1500 form, yes. In the Medicare Claims Processing Manual, Chapter 3, Section 10.4, it states that all items in non-physician services provided by an outside entity that are provided during the inpatient stay will be billed through your facility under arrangements. If you do not have arrangements, then you will need to set these up with those providers.

Q16. We bill as a rehab agency on the UB04. With the billing manual, Chapter 3, Section 10.4, when it states we can bill hospitals for PT that’s outpatient under arrangements. Is there a system we need to follow for those payment arrangements?
A16. Nowhere does CMS publish that you need to follow X, Y, or Z. The services need to be defined upfront. Both facilities should come to agreement on (a) the services that are going to be provided, and (b) the payment or reimbursement for those services. CMS has a best practices website that can be referenced for these situations - Best Practices Guidelines | CMS.