ACT Questions and Answers - September 15, 2021

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.

Medicare Program Updates

  1. CMS Website: CMS has changed the look of the home page on their website. All the information remains easily accessible.
  2. CMS Current Emergencies: Providers can access the CMS website to access current information and any changes that may occur throughout the duration of the pandemic.

Questions and Answers

Q1: A patient is receiving treatment for cancer, however, is being admitted for something else. But the patient is scheduled for treatment during that admission. Can the patient continue his or her care while in the hospital and have their cancer treatments continued as this is being billed under Drug Related Grouping (DRG) weight or would this basically be double dipping and patient will need to discharge under 30 and register for their cancer treatment and return for continued care under new admission?
A1: Yes, treatment can continue when the inpatient admission is unrelated and be billed through the inpatient hospital provider under arrangement. Per CMS IOM, Publication 100-04, Chapter 3, Section 10.4, all items and nonphysician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. Providers are also required to report all diagnosis codes on an inpatient claim as well as the Present on Admission (POA) indicators. This is used in determining the DRG grouping.

Q2: The newest version of the L34106 Local Coverage Determination (LCD) policy indicates that all patients presenting with Vertebral Compression Fracture (VCF) should be referred for evaluation of Bone Mineral Density (BMD) and osteoporosis education for subsequent treatment, as indicated, and all patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program. Most patients in need of this procedure already have an established diagnosis of osteoporosis and are subsequently already on treatment with Prolia. Can you please clarify, if in these instances, the above criteria would not apply? The patient would already be following up yearly with their physician for the treatment of osteoporosis. Would this only apply to newly diagnosed patients?
A2: Performers of vertebroplasty should note that the beneficiary is under treatment and with what. The key is you cannot just do the procedure without showing that you are thinking about the treatment of the underlying disease. This must be clearly documented in the medical record.

Q3: Per CMS IOM Publication 100-02, Chapter 15, Section 220.1.2.B regarding Plans of Care for Physical Therapy (PT), Occupational Therapy (OT), or Speech-Language Pathology Services (SLP): "The duration is the number of weeks, or the number of treatment sessions, for this Plan of Care." Per this definition, the duration would be a documented number of weeks (e.g., six weeks) or sessions (e.g., 12 sessions).  Is it acceptable to document the 'duration' of the services using the end date of a certification? For example: Instead of documenting three times per week for six weeks, would it be acceptable to document three times per week through the certification end date?
A3: To reflect a clear measurable duration to meet IOM requirements it would be appropriate to note the frequency through the certification end date of XX/XX/XX. It is recommended that the end date is listed in this example.

Q4: Can we get education on the appropriateness of the KX modifier when it comes to Cardiac Rehab? According to CMS IOM Publication 100-04, Chapter 5, Section 10.3 the KX modifier should only be used if documented medically necessary services exceed the therapy cap; in this case the initial 36 sessions of cardiac rehab. Also, if a beneficiary has a new cardiac event and needs rehab again, would this be 36 sessions without the KX modifier or is this not a lifetime max of 36 sessions?
A4: IOM Publication 100-04, Chapter 5, Section 10.3 refers to Part B Outpatient Rehabilitation and CORF/OPT Services. Comprehensive Outpatient Rehabilitation Facilities (CORF) can provide respiratory therapy services per IOM Publication 100-02, Chapter 12, Section 40.5. The respiratory plan of treatment must be wholly established by the referring physician before therapy is initiated. Respiratory therapy must be provided by a respiratory therapist. Respiratory therapy services are reported with Healthcare Common Procedure Coding System (HCPCS) G0237, G0238, and G0239 with no therapy modifiers. The plan of treatment must be reviewed upon the duration of the plan of treatment or at least every 60 days. HCPCS G0237, G0238, and G0239 are not subject to the therapy caps, therefore, the KX modifier would not be applicable. The documentation must demonstrate the medical need for skilled therapy and that the beneficiary is making progress toward one or more of the rehabilitation goals. Medicare coverage ends with respect to that aspect of the rehabilitation plan of treatment.

Coverage criteria for cardiac rehabilitation services are covered in the IOM Publication 100-02, Chapter 15, Section 232. Cardiac rehab services cannot be billed on the CORF Type of Bill (TOB) 75x. Per the IOM Publication 100-04, Chapter 32, Section 140.2.2, Cardiac Rehab (CR) and Intensive Cardiac Rehabilitation (ICR) services should be submitted on TOB 13X or 85X only for institutional claims. Contractors shall accept the inclusion of the KX modifier on the claim line(s) as an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the requirements of the medical policy or, for ICR, that any further sessions beyond 72 sessions within a 126 day period counting from the date of the first session or for any sessions provided after 126 days from the date of the first session meet the requirements of the medical policy. Beneficiaries who switch from ICR to CR may also be eligible for up to 72 combined sessions with contractor discretion for CR sessions after 36 (to include completed ICR sessions prior to switch). In these cases, and consistent with the information above, the KX modifier must be included on the claim should the beneficiary participate in more than 36 CR sessions following the switch.
Change Request 7470, Common Working File (CWF) Editing Update for Pulmonary Rehabilitation Services (PR) states that the Common Working File (CWF) edit is set up to deny CR and ICR services that exceed 72 services provided within 18 weeks without the KX modifier.

When there is a new cardiac event beyond the 18-week time period, the coverage for CR sessions would re-start with the 36 sessions. 

Q5: Please validate the billing guidelines about two different visits on same date. This is for services that overlap with revenue codes 0360 and 0450. The first service, outpatient surgery, is provided. The second visit is an emergency service follow-up on the wound.  Are these two services paid separately? 
A5: These claims should be combined, especially if related to the procedure. The condition code G0 (G "zero") would not apply as they are not the same revenue center. The Integrated Outpatient Code Editor (I/OCE) Specifications file in the CMS I/OCE Quarterly Files provides different examples when the G0 condition code should be applied.

Q6: I understand how to use the ET modifier for emergency room (ER) services when a patient is in-house at a Skilled Nursing Facility (SNF) and receiving emergency room services at a Part A facility spanning multiple days.  Does the ET modifier apply to any emergency room services related to consolidated billing? We bill for a mental health facility and the patient is seen at an emergency room at a Part A Prospective Payment System (PPS) hospital and then is evaluated and transferred to an inpatient PPS Behavioral Health Facility.  I would like to know if it is appropriate to use the ET modifier on the emergency room visit when the patient dates span 01/01/21-01/02/21 and is admitted to the Behavioral Health Facility on 01/02/21 or is the ET modifier only used when a patient is inhouse at a SNF.
A6: The ET modifier is used to exempt ER services from consolidated billing.  It can be used when patient is an inpatient at a SNF in a Part A covered stay and to indicate ER-related services are excluded from End Stage Renal Disease (ESRD) consolidated billing for patients on maintenance dialysis. The ET modifier would not be appropriate for an inpatient PPS Behavioral Health Facility.

Q7: Does Noridian have any guidance in relation to billing for the donor and recipient charges for fecal transplants? Is this a covered service for the recipient; and do the donor's charges get billed to the donor's respective insurance, or would they be covered under the recipient? Would all charges get billed to each the donor and recipient’s respective insurance?
A7: G0455 is the correct code for Fecal Microbiota Transplant which includes the obtaining and processing of the donor specimen and is billed to the recipient. In lieu of a coverage policy, the medical record must demonstrate that the service provided is medically necessary for treatment of the beneficiary’s condition.

Q8: The current Local Coverage Article for Treatment with Yttrium-90 Microspheres (A52950) provides instruction on how to bill for Theraspheres as a product with Food and Drug Administration (FDA) Humanitarian Device Exemption (HDE) approval with the HDE number. As of March 17, 2021, Boston Scientific (the current manufacture of Theraspheres) received premarket approval for Therasphere, therefore, changing the HDE status of the product. Can you please provide instruction on how to bill future claims in which Theraspheres (C2616) is used to be able to differentiate it between the SIRTEX product, now that the HDE number will not be utilized? Both products have different covered diagnosis codes.
A8: If the product no longer had HDE status, the claim would be reported using the appropriate revenue code (not 0624) and would be coded with the correct diagnosis code per the article. The patient’s medical record would also need to reflect what product was used to ensure it matches the diagnosis codes billed.

Q9. Please refer to CMS Change Request (CR) 11792 as CPT code 12001, along with others, was removed from the Rural Healthcare Clinic (RHC) Qualifying Visit List on 07/2020.  CMS does NOT update the master RHC Qualifying Visit List, they just release the change request (CR11792), and it makes it official. CPT code removed/excluded from the RHC Qualifying Visit list effective 07/2020: 10060, 11721, 12001, and 20604. How are we as a RHC to get paid for this visit? Would we automatically attach an Evaluation and Management (E&M)?
A9: No, automatically attaching an E&M code only to receive payment would be a fraudulent billing practice and you could lose the privilege to bill Medicare altogether. Per CR 12187, effective 04/01/2021 the following codes were removed from the list and are now billable/payable using the CG modifier: 10060, 11721, 11750, 11765, 12001, 20600, 20604, 29580, 69200, and 69210. Furthermore, the CMS I/OCE Quarterly Files contain a MAP_CONFLICT RHC file that determines services deemed incorrectly reported with modifier CG (Policy criteria is applied) for RHC claims are line item rejected. Complete information can be found in the, CMS MLN Matters MM12187 Article.

Q10: We are a Federally Qualified Health Center (FQHC) and according to CMS guidance, COVID-19 vaccine administration payment is made at the time of cost settlement. A COVID-19 vaccine only service does not qualify as an eligible PPS visit. We submitted several COVID-19 vaccine administration claims to Noridian for report purpose, but the claims were returned to the provider with reason code: 31744. We understood that COVID-19 vaccine administration payment is made at the time of cost settlement, however, I believed that we would need to submit data to Medicare. Otherwise, how can the services be reconciled at the end of the year? As well as Medicare Advantage (MA) patients, we need to bill original Medicare since MA plans are not financially responsible for COVID-19 vaccine administration. Do we submit the claims to Part B (Medicare FFS)? We tried to submit the COVID-19 vaccine administration claims to MA Wrap-around, but the claims were returned to provider also for same reason code.
A10: The COVID 19 vaccine and its administration are paid at 100 percent of reasonable cost through the cost report. No visit is billed, and these costs should not be included on the claim. Costs for all COVID-19 vaccines should be included on the cost report information. Therefore, a claim for COVID vaccines should not be submitted.

Q11: If a CERT audit identifies an improper payment for inpatient level of care as not medically necessary, and we agree with the CERT decision, is the facility allowed to rebill for Part B charges if the DOS falls within timely filing? Please see CMS IOM 100-04, Chapter 4, Section 240.1 - Editing of Hospital Part B Inpatient Services: Reasonable and Necessary Part A Hospital Inpatient Denials for reference.
A11: Yes, if you are within timely filing for A-to-B Rebilling, it is appropriate to rebill those charges.  Directions for A-to-B Rebilling can be found in CR8445 and CR8666.  Please be aware that CMS has removed special edition, SE1333, that contained additional instructions.

Q12: The hydration billing and coding coverage article indicates that a clinical assessment would typically be performed prior to hydration being ordered for a patient's anticipated fluid needs. In cases of nephrotoxicity, our oncology physicians order hydration based upon reviewing the patient's lab work for elevated creatinine levels, which indicates the presence of nephrotoxicity. In these instances, would hydration still be considered medically necessary without a provider clinical assessment because the decision to order hydration for nephrotoxicity is based upon the presence of elevated labs only? Or would Noridian still expect to see a clinical assessment in the medical record for these scenarios?
A12: A clinical assessment is helpful, but not essential. The labs can provide some of the documentation for the medical necessity for why IV fluids are given but should not be the only documentation. There would also need to be notes by the provider based on what the labs reflected on why IV fluids are needed. For example, the documentation would need to show what chemo drug was given and if it is nephrotoxic, the note would indicate chemo drug is nephrotoxic and the labs are showing a need for hydration. Also, it would be expected to see fluids given on the same day as the drug.
Q13: When fluids are given at a high rate for trauma patients for treatment of shock or burns, when fluids are used for a patient with kidney stones or diabetic ketoacidosis (not dehydration) is this still considered hydration and how do we determine the time of hydration?
A13: As for the specific scenarios presented, we try and stay away from specific scenarios as the documentation would need to support each claim billed. Hydration services need to meet the definition of the CPTs as listed in the American Medical Association (AMA) coding book. Also, as indicated in the article, "In conclusion, the main question that should be asked when considering billing for 96360 and 96361 is whether IV hydration is an appropriate, accepted standard of medical practice as a diagnostic or specific treatment for a beneficiary’s condition, is one that meets, BUT does NOT exceed the beneficiary’s medical need, and cannot be met with oral hydration." The billing and coding article also provided information on how time is calculated, "infusion time is calculated from the time the administration commences (i.e., the infusion starts dripping) to when it ends (i.e., the infusion stops dripping)." Also, if the time is less than 31 minutes, the codes cannot be reported as per the AMA since these codes reflect time.

Q14: How do we report when fluids are given for dehydration but at a slow rate as to not induce fluid overload for patients with Congestive Heart Failure (CHF) or kidney disease? How do we determine the time of hydration?
A14: The documentation needs to clearly indicate by the ordering provider, the concern of fluid overload and why the infusion was given so slowly. The billing and coding article, A54635 for JE, A52732 for JF, provides guidance on how time is calculated "infusion time is calculated from the time the administration commences (i.e. the infusion starts dripping) to when it ends (i.e. the infusion stops dripping)."

Q15: Can Noridian please clarify if advanced practice providers (AAP) can order diagnostic mammograms? The NCD for Mammograms (220.4) reflects these can only be ordered by a doctor of medicine or osteopathy, however, the Code of Federal Regulations (CFR), title 42, section 410.32, Diagnostic x-ray tests, diagnostic laboratory test, and other diagnostic tests indicate that non-physician practitioners who furnish services that would be physician services furnished by a physician, and who are operating within their scope of their authority under State law, may be treated the same as physicians treating beneficiaries. Can APPs order diagnostic mammograms? 
A15: Yes, as long as it is within the advanced practice providers scope of practice.

Q16: When a patient is seen in an RHC, and is subsequently sent to Critical Access Hospital (CAH) to be seen in the ER and possibly admitted, can the RHC bill a visit in addition to the visit that will be billed by a different provider in the ER or the admitting provider if admitted to the CAH?
A16: Yes, the RHC can bill a visit in addition to the visit that will be billed by a different provider.  

Q17: When providing the drug Xolair, J2357, we are wondering how many instances of 96372 can be billed. We purchase syringes of Xolair that come in 150 and 75 mg vials. The MUE is 5. The patient has to be injected in 2 different locations. The manufacture states that no more than 150 mg can be injected in one site. Can we bill 96372 x 2 for two subcutaneous injections for two different locations on the body? Can three units of 96372 be billed for 150 mg in one site, 75 mg each in two separate sites? Which line requires a modifier 59? Is the 76 modifier applicable as this is incident to a physician service? Where are instructions published?
A17: The Current Procedural Terminology (CPT) code 96372 (Therapeutic, prophylactic, or diagnostic injection) can be billed for two units since this has to be given in two syringes at two different sites. A modifier is not needed. It would not be medically necessary to divide the dose into three syringes per the FDA guidelines, therefore, billing three units would be inappropriate. The Medically Unlikely Edits (MUE) for the administration CPT code, 96372, is five and for HCPCS code J2357 (Xolair) the MUE is 120.
Jurisdiction E (JEA) Initial Drug Administration
Jurisdiction F (JFA) Initial Drug Administration

Q18: Regarding therapeutic infusion coding, 96365, (Intravenous infusion). Patients come in 12 hours apart for antibiotic infusions and we are receiving denials for second infusion. We used to bill the second line item of 96365 with either the 59 or XE modifier noting the second encounter. We have received guidance to bill the second line item with 96366 (Each additional hour).
A18: Per the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 11, CPT codes 96360, 96365, 96374, 96409, and 96413 describe "initial" service codes. For a patient encounter, only one "initial" service code may be reported unless it is medically reasonable and necessary that the drug or substance administrations occur at separate intravenous access sites. To report 2 different "initial" service codes, use National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP)-associated modifiers.

Per CPT Coding Manual: "When reporting multiple infusions of the same drug/substance on the same date of service, the initial code should be selected. The second and any subsequent infusions should be reported based on the individual times of each additionally infusion(s) of the same drug/substance using the appropriate add-on code. Example: In the outpatient observation setting, a patient receives one-hour intravenous infusions of the same antibiotic every 8 hours on the same date of service through the same IV access. The hierarchy for facility reporting permits the reporting of code 96365 for the first one-hour dose administered. Add-on 96366 would be reported twice (once for the second and third one-hour infusions of the same drug)". The CPT manual also states that only 1 initial/primary code can be billed per date of service.

Q19: We need a definition of an encounter. When the patient leaves the facility for a period of time and they are re-registered for the second infusion, that is counted as a second encounter.
A19: For planned infusion services when the patient returns for an additional infusion of the same drug, Outpatient Perspective Payment System (OPPS) services of multiple administrations provided on the same day would be on the same claim unless they are different; and the G0 condition code would need to be reflected on the claim.

Please refer to the following resources for additional information:
CMS Change Request 7271
Jurisdiction E (JEA) Chemotherapy Administration Billing
Jurisdiction F (JFA) Chemotherapy Administration Billing

Q20: We are using Spinraza to treat patients with spinal muscular atrophy with an intrathecal administration method. We bill outpatient hospital services (UB-04 claim form) and physician services (CMS 1500 claim form). We are seeking clarity on which is the appropriate code to report for Spinraza; 96450, 62322 w/out and 62323 w/imaging guidance), or 64999 unlisted procedure code in nervous system with an inserted comment for the Spinraza administration. There is an understanding CPT codes 62322 and 62333 are in an LCD for injections into lumbar and spine which would differ for our intended use.
A20: Spinraza (nusinersen) (HCPCS code J2326) is a medication that was approved in December 2016 by the U.S. FDA for the treatment of all forms of spinal muscular atrophy (SMA). Spinraza is administered by intrathecal injection and should be billed using CPT code 96450 - Chemotherapy administration, into CNS (e.g., intrathecal), requiring and including spinal puncture.

Q21: We noticed mass reprocessing of chest x-rays from 09/20/2020 through 01/07/2021. The mass reprocessing finalized on 01/17/2021. Why did this occur?
A21: Per the Local Coverage Determination (LCD), L37549 Chest X-Ray Policy, "There are thousands of diagnoses which would constitute reasonable and necessary conditions for chest X-rays. Despite that, Noridian data shows that there are a large number of chest radiographs that do NOT appear reasonable and necessary. To simplify this policy, and for physicians to be reimbursed for chest X-rays and avoiding coding errors, we are converting this to a negative policy.

Noridian is listing those diagnoses that are not reasonable and necessary based on literature from medical societies and clear community standards and for which the data analysis shows are the more common reasons for a denial. A chest X-ray that is not reasonable and necessary contributes to unneeded patient radiation exposure, patient anxiety, unnecessary visits to a medical or radiology facility, and increased costs to both patients and the Medicare Trust Fund."

In September 2020, a system issue was identified for OPPS claims causing claims to deny incorrectly if a non-payable DX code was anywhere on the claim causing the entire claim to deny. The issue was corrected and a mass adjustment ran to correct the issue.

Q22: Tocilizumab, a monoclonal antibody treatment for hospitalized adult or pediatric patients two years and older who must have systemic corticosteroids and supplemental oxygen before you can bill the administration fee of M0249, and M0250. What is considered hospitalized? When a COVID positive patient comes into the Emergency Department (ED) and there are no hospital beds available, if an inpatient order is written and Tocilizumab monoclonal antibody treatment is ordered, is that considered hospitalization?
A22: Yes, Treatment can be provided in the hospital inpatient or outpatient setting. The hospital stay begins when there is a written order by the physician to admit.

Tocilizumab, a monoclonal antibody treatment, must be provided for patients with a positive COVID-19 test result and are at high risk for progressing to severe COVID-19, hospitalization, or both. Healthcare providers may administer monoclonal antibody therapies only in settings where they have immediate access to medications to treat a severe infusion reaction, such as anaphylaxis and the ability to activate the emergency medical system (EMS).
Please refer to the following resources for additional information:
CMS Monoclonal Antibody COVID-19 Infusion
CMS Covid-19 Vaccines and Monoclonal Antibodies


Last Updated Apr 12 , 2023