Article Detail - JE Part A

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

Questions and Answers

Q1: Inpatient discharge to home under a plan of care for home health services is discharge status code 06. Per MLN Matters SE21001, if no home health services furnished within three days of hospital discharge, add the condition code 43. This seems clear for a situation when home health services were not initiated until five days after discharge, but if by day 30 no home health services had been provided (and unlikely will be provided at all) due to various reasons including possible patient refusal to continue with the plan of care? Is using discharge status code 06 and condition code 43 still correct even if no home health services are provided, or should the claim be corrected as if discharged home, status code 01? The MLN Matters article cited has no language specific to this, but a response from someone in the Noridian contact center confused us. It was stated that there is a 30-day threshold for billing status code 06 based on the Home Health PPS 30-day payment rate. Under the Medicare Benefit Policy Manual, Chapter 7, Section 10, the unit of payment under the home health PPS is a 30-day period rate. Thus, if no home health services by day 30, discharge status code should be changed to 01. Is the home health PPS 30-day payment unit relevant to hospital billing for determining the discharge status code?
A1: If the continuing care is related to the hospital admission but the home health agency does not provide the services within three days of discharge, the hospital can apply condition code 43 to the inpatient claim and receive the full MS-DRG payment. Per MLN Matters SE 1411, there is no threshold for using the condition code 43. Some other resources include CMS MLN SE20025 - Review of Hospital Compliance with Medicare's Transfer Policy with the Resumption of Home Health Service and the Use of Condition Codes and OIG Inadequate Edits and Oversight Cause Medicare To Overpay More Than $267 Million for Hospital Inpatient Claims with Post-Acute-Care Transfers to Home Health Services.

Q2: What are the rounding rules for observation hours when the total hours are not a whole number? Do the standard numerical rounding rules apply? If the hours total are 12 hours and 01 minute are 12 hours and 29 minutes, then round down to 12? If the hours total are 12 hours and 30 minutes to 12 hours and 59 minutes, then round up to 13? Or is it if the hours total are between 12 hours and 01 minute and 12 hours and 59 minutes, then round up to 13 hours? IOM 100-04, Chapter 4, Section 290.2.2 states: "hospitals should round to the nearest hour", but the only example provided uses 3:03 pm to 9:45 pm (6 hours and 42 minutes), it’s not clear how minutes under the 30-minute mark are to be rounded.
Clarification provided below based on response from CMDs on A2: published 04/22/2022 A2: The provider should round the start time and the end time, then calculate the total hours. The times should be rounded to the nearest hour, down from :29 and under and up for :30 and above. For example, if observation began at 3:29 pm and ended at 9:31 pm, the total hours would be calculated using the span of 3:00 pm to 10:00 pm for a total of 7 hours. If the total hours are calculated first, then rounded, the result would be different than using the process outlined in the claims processing manual.

Corrected answer published 06/13/2022 A2: The provider should round the start time and end time, then calculate the total hours. The times should be rounded to the nearest hour, down from :30 and under and up for :31 and above. For example, if observation began at 3:29 pm and ended at 9:31 pm, the total hours would be calculated using the span of 3:00 pm to 10:00 pm for a total of 7 hours. If the total hours are calculated first, then rounded, the result would be different than using the process outlined in the claims processing manual. Observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure (e.g., colonoscopy, chemotherapy). In situations where such a procedure interrupts observation services, hospitals may determine the most appropriate way to account for this time. For example, a hospital may record for each period of observation services the beginning and ending times during the hospital outpatient encounter and add the length of time for the periods of observation services together to reach the total number of units reported on the claim for the hourly observation services HCPCS code G0378 (Hospital observation service, per hour). A hospital may also deduct the average length of time of the interrupting procedure, from the total duration of time that the patient receives observation services.

Q3: On pain management claims, do we bill under the ordering provider or the CRNA that provided the service? If it is billed under the CRNA, does the CRNA need to be credentialed in the same manner as NP, PA, DO, etc.?
A3: The CRNA would be on the claim as rendering the service and would need to follow the credentialing process on our Anesthesia and Pain Management webpage.

Q4: When a patient wants to use his Veterans’ Administration (VA) benefits and the patient gets admitted to inpatient care or even swing bed care (we get appropriate authorization from the VA), do we need to shadow bill Medicare for this type of care (TOB 11X, TOB 18X)? If so, how do we get our shadow bill claims to go through to Medicare without denying? We are using condition code 04 and removing the professional fees. Do patients need to call Medicare and let them know they have veterans’ insurance as well?
A4: Per CMS MLN MM9818, VA claims do not need shadow claims. No, the beneficiary would not need to call, you will document it on the claim. If the VA approved the services, the VA would pay for those services, submit your claim to the VA, you do not need to send a claim to Medicare. If the patient is receiving VA-approved services and non-VA approved services that are also Medicare services, those services can be billed to Medicare. Bill the VA for the VA approved services. Bill Medicare with a 26-condition code is required stating this patient also has VA benefits. A 42-value code with the amount the VA paid toward the VA approved services.

Q5: For research billing, are we able to bill the administration of placebo during a blinded trial?
A5: No, this is not part of the traditional routine costs associated with the service. If it is necessary for a provider to show the items and services that are provided free-of-charge in order to receive payment for the covered routine costs. For more information, please review the Medicare Claims Processing Claims Manual, Chapter 32, Section 69.5 and CMS MLN MM10521.

Q6: If we have already submitted some shadow billing claims, should I go in and cancel those claims to Medicare that I shadow billed? They would not match up with the Medicare Advantage claims.
A6: Shadow bills should only be submitted for non-VA authorized services. If the VA covers 100 percent of the claim, then any other claim should not be submitted.

Q7: I have a date of service of 11/21/2021 through 12/21/2021. For November, the patient has Blue Cross Blue Shield (BCBS) and they kept on denying saying Medicare is primary. The portal still shows for November the patient had the BCBS coverage until 11/30/2021 and then on 12/01/2021, the patient enrolled in a Medicare Advantage plan. Am I allowed to split bill my claim from the November dates of service to the Medicare Advantage plan that became active in December?
A7: The Medicare Claims Processing Manual, Chapter 1, section 90 outlines when a Medicare Advantage is only applicable during a portion of an inpatient claim. Prospective Payment System (PPS) providers would not split their claims, they would bill admit or discharge, depending on who was primary upon admission would be the primary on the entirety of that claim. Non-PPS provider would split.

Q8: We are starting to receive denials for CPT code 86053 for not medically necessary with denial code CO50. We cannot find an LCD or an NCD on this.
A8: Noridian has L34215 and A57689 for Jurisdiction E and L36094 and A57690 for Jurisdiction F on Lab Flow Cytometry.

Q9: If we did not get a signed and dated inpatient physician order, are we still able to bill on the claim?
A9: This would be a self-audited claim. In the Medicare Claims Processing Manual, Chapter 4, section 240, it outlines which revenue codes are allowed on the claim and which ones are not. In addition, if the CA modifier is applicable, such as the patient expired prior to being admitted, that would be billed on a 13X type of bill.