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.

Medicare Program Updates

1. CMS Website: CMS has changed the look of its 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: When a single patient encounter begins greater than 3 calendar days prior to an inpatient admission, how are the outpatient charges incurred more than 3 days prior to the inpatient admission to be billed? We understand all charges, diagnostic and non-diagnostic, for the 3 calendar days preceding the inpatient admission must be bundled into the inpatient bill, as they are related and so included in the payment window, but what about the outpatient services provided greater than 3 days prior to inpatient admission? Would those outpatient services outside the payment window be separately billed as outpatient, even though all services were provided during a single continuous encounter?
A1: The outpatient charges are incurred on a 13X TOB. All outpatient services provided prior to the payment window are billed as outpatient services. The services would be separately billed as outpatient even though all the services were provided during a single continuous encounter.

Q2: If we admit a patient that has a positive home test, does physician or nursing documentation that they had a positive home test qualify for the extra 20% on the DRG payment or do we need to retest the patient again to have a lab result in the record? Please advise what your stance is on this as the CMS MLN SE20015 does not address it nor has it been updated to address it.
A2: If the beneficiary has a positive home COVID-19 test it is prudent and Noridian expects the facility to confirm the home test by retesting the beneficiary due to the important implications that a positive test brings in regard to isolation and patient care. If the test was negative, the entity should consult with their medical staff and local/state health departments as to whether further testing is required while considering that a negative test in a COVID-19 positive patient could be due to improper home testing technique.

Q3: Per Coding and Coverage Article for Billing and Coding: Infusion, Injection, and Hydration Services (A53778), CMS indicates that the facility (based on CMS definition of provider) can calculate an end-time for an infusion and use that to charge for hydration. Does Noridian ascribe to this definition also? Does this calculation of end-times apply to therapeutic infusions as well?
A3: Please understand that this is not a CMS article, it is an article from another MAC and providers in JE and JF cannot use another contractor's article as a reference for services performed in Noridian's jurisdiction. Providers must follow the guidance in our Billing and Coding: Hydration Services (A54635) that indicates the following:

• When administering multiple infusions (e.g., IV fluids and subsequent IV chemotherapy infusion on same date of service), only one primary infusion code should be reported for a given date, unless protocol requires that two separate IV sites must be used.
• Hydration cannot be reported concurrently with any other infusion or drug administration service.
• The definition of infusion time is inherent and presented in the guidelines for these codes. In other words, a minimum time duration of 31 minutes of hydration infusion is required to report the service.
• Consequently, infusion time is calculated form the time the administration commences (i.e., the infusion starts dripping) to when it ends (i.e., the infusion stops dripping)

We are also discussing internally clarifying if the outpatient hospital setting is considered a physician's office. Please watch our website for any future updates to this article.

Q4: According to CMS MLN SE20016, RHCs should bill revenue code 0900, along with the appropriate HCPCS code for the mental health visit along with modifier CG and 95 for audio/video (audio-only use modifier FQ). Does this mean that only the therapy codes are allowed as covered RHC mental health telehealth services? When mental health providers furnish both an evaluation and management office visit (99213-99205) and psychotherapy (ex: +90833), will both services use revenue code 0900 and the RHC receive payment as both codes must be billed together?
A4: In CMS MLN SE22001, there is an example for RHC billing Mental Health Visits via Telecommunications. Per the CMS IOM Publication 100-04, Chapter 9, Section 60.1, since RHCs are not required to report detailed HCPCS codes, payment is applied to the service line with revenue code 052X and 0900 for mental health visits.

Q5: Revenue codes 0260, 0270, 0271, 0272, and 0636 are being automatically noncovered for our MRCE IP Part B Only and A/B Rebilling TOB 12X claims. According to the IOM 100-04, Chapter 4, Sections 240.1 and 240.2, these revenue codes are allowable and payable. We have contacted Noridian getting different reasons and are told there is a system issue and to resubmit a TOB 127 leaving the charges covered and they would be paid. These claims are returned to the provider (RTP) with reason code 30960. IT has been communicated to us this is from CMS, however, no update has been sent from CMS or Noridian for providers to update their billing system to auto adjust these off.
A5: CMS recently directed MACs to implement appropriate editing for Inpatient ancillary claims billed on a 12X TOB in Change Request (CR) 12816. There are two different scenarios that providers use to bill 12X TOB. The first is defined in the CMS IOM Publication 100-02, Chapter 6, Section 10.2 for reasonable and necessary Part A Hospital Inpatient Claim denials. These claims, commonly referred to as A/B Rebill claims, are billed after either a self-audited claim is submitted by the provider with an M1 Occurrence Span code, or after a claim is denied by a Contractor (including the MAC, RAC, SMRC, OIG, QIO, etc.) and providers do not intend to file an appeal. The MBPM Ch 6 section 10.1 outlines the billable services for these 12X TOBs. Due to the newly implemented editing, Noridian has seen a large increase in providers billing these claims incorrectly causing the editing to occur with the recent shared system updates. Common billing errors include:

1. Failure to submit a self-audited inpatient claim (TOB 110) with an M1 OSC before submitting a 12X TOB.
2. Failure to submit the correct coding outlined in the MCPM Ch 4, section 240.1 including:
   1. A condition code "W2" attesting that this is a rebilling and no appeal is in process,
   2. "A/B REBILLING" in the treatment authorization field, and NOTE: must be exact, many examples include missing or incomplete data in the treatment auth field i.e. A/B REBILL
   3. The original, denied inpatient claim (CCN/DCN/ICN) number. NOTE: Providers submitting an 837I are instructed to place the appropriate Prior Authorization code above into Loop 2300 REF02 (REF01 = G1) as follows: REF*G1*A/B REBILLING~ For DDE or paper Claims, "A/B Rebilling" will be added in FL 63.

Failure to report an appropriate self-audited claim or failing to wait for the contractor reviewed inpatient claim to deny, will cause these claims to hit out incorrectly.

The second scenario that a provider would bill a 12X TOB is outlined in the CMS IOM Publication 100-02, Chapter 6, Section 10.2, these claims are for Other Circumstances in Which Payment Cannot be Made under Part A. Examples include patients with no Part A entitlement, or patients who have exhausted their inpatient Part A benefits. The long-standing policy outlined in the Medicare Benefit Policy Manual outlines the services billable for these cases. We note that it is a much shorter list than those for reasonable and necessary inpatient denials and generally include preventive services, certain kinds of drugs, and diagnostic services.

While the table referenced in the Medicare Claims Processing Manual Chapter 4 sections 240.1 and 240.2 is still a valid table for revenue codes not allowed on these bills, the shared system has been updated to ensure that the services billed on allowable revenue codes fall into one of the categories defined in the MBPM Ch 6 section 10.2. Services not meeting the definition of allowable services outlined in this manual are hitting correctly.

Furthermore, denials for these services do not deny contractually, rather as patient responsibility as services other than those defined in the MBPM CH 6, section 10.2 would be covered under Part A. For this reason, there is no need to update your system to "adjust these off".

After the ACT, Noridian wanted to provide further clarification:

On September 8, 2022 CMS issued Change Request (CR) 12816 which directed MACs to implement appropriate editing for Inpatient ancillary claims billed on a 12X TOB. CR12816 updated the revenue codes that are and are not allowed on a 12x TOB.

On May 2, 2003 CMS issued CR 2614 which shows revenue codes 0260, 0270, 0271, and 0272 are packaged revenue codes for which no separate payment is made. However, the cost of these services is included in the transitional outpatient payment (TOP) and outlier calculations.

Any other revenue codes that are billable on a hospital outpatient claim must contain a HCPCS code in order to assure payment under OPPS. Return to provider (RTP), claims which contain revenue codes that require a HCPCS code when no HCPCS code is shown on the line.

Q6: Are CPT codes 94625 and 94626 the correct codes for facility charging in a critical access hospital for pulmonary rehabilitation?
A6: As long as your state allows representation of the facility as a place of service (POS) 22 (on-campus outpatient hospital), Pulmonary Rehabilitation Services (A56152) applies.

Q7: Is it appropriate to use modifier CS when a patient presents to the emergency department for symptoms/conditions unrelated to COVID-19, but the patient is tested for COVID prior to transfer to a higher level of care? Example: Patient presents to our emergency department with abdominal pain. The patient is worked up and found to have acute appendicitis. The patient required urgent transfer to a different facility for an appendectomy. Prior to leaving our facility, a COVID-19 test was performed to screen for COVID before the patient had surgery. Is it appropriate to add modifier CS to the facility emergency department code/charge, revenue code 0450, and to the professional charge code/charge, rev code 0981?
A7: Per CMS MLN SE20011, cost-sharing doesn't apply for COVID-19 testing-related services, which are medical visits that are provided between March 18, 2020 and the end of the public health emergency (PHE) that result in an order for or administration of a COVID-19 test; are related to providing or administering such a test or to the evaluation of an individual for purposes of determining the need for a test; and are in any of the following categories:

• office and other outpatient services
• hospital observation services
• emergency department services
• nursing facility services
• domiciliary, rest home, or custodial care services
• home services
• online digital evaluation and management (E/M) services

Q8: When there is an incomplete colonoscopy due to unforeseen circumstances and the physician is unable to advance the colonoscope past the splenic fixture, is the incomplete colonoscopy billed with CPT code 45330-45331 or do we follow CMS IOM Publication 100-04 Chapter 12, Section 30.1B and use 45378-53, G0105-53, or G0121-53?
A8: Per the publication noted above, an incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier "-53." (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. Since January 1, 2016, Medicare pays for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.

Q9: When a physician diagnoses a patient with any form of malnutrition, and he/she utilizes the RDs documentation for the Aspen criteria to support the clinical aspects of the diagnosis, doe the RD signature need to reflect "electronically signed by" and follow the provider signature guidelines versus the EMR reflecting who the entry was generated by with his/her name only?
A9: Clinical documentation should be authenticated by the clinicians who complete them. We do have our Medical Documentation Signature Requirements webpage that educates on electronic signature guidelines. In the case that medical records are requested, it is always best practice to include the facility's electronic signature process to support any electronic signatures.

Q10: Our hospital district owns and operates two hospitals and they share a tax identification number (TIN). FISS will reject outpatient claims from one hospital if there is an inpatient claim with an admit date within 72 hours of date of service at the other hospital because it is looking at the shared TIN. Per page 73286 of the Federal Register Volume 76, Issue 228, "Corporation Z owns Hospitals A and B. If Hospital A performs preadmission services and the patient is subsequently admitted as an inpatient to Hospital B, are the services subject to the payment window? Policy: No. The payment window does not apply to situations in which both the admitting hospital and the entity that furnishes the preadmission services are owned by a third entity. The payment window includes only those situations in which the entity furnishing the preadmission services is wholly owned or operated by the admitting hospital itself". From this definition, the 72-hour rule does not apply. How can FISS differentiate between hospitals? Should FISS be looking at NPI or PTAN instead?
A10: Medicare's 3-day payment window applies to outpatient services that hospitals and hospitals wholly owned or wholly operated Part B entities furnish to Medicare beneficiaries. The statute requires that hospitals bundle the technical component of all outpatient diagnostic services and related non-diagnostic services with the claim for an inpatient stay when services are furnished to a Medicare beneficiary in the three days (or, in the case of a hospital that is not a subsection (d) hospital, during the 1-day admission) preceding an impatient admission in compliance with Section 1886 of the Social Security Act. The three-day payment window applies to services provided on the date of admission and the three calendar days preceding the date of admission that will include the 72-hour time period that immediately precedes the time of admission but may be longer than 72 hours because it's a calendar day policy, according to CMS MLN SE20024 - FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients. The 1-day payment window applies to the date of admission and the entire calendar day preceding the date of admission and will include the 24-hour period that immediately preceded the time of admission but may be longer than 24 hours.

After the ACT, Noridian wanted to provide more clarification:

Noridian encourages the entity to review their CMS 855A application and make corrections as needed via Provider Enrollment, Change and Ownership System (PECOS) web application.

Q11: Per Conditions of Coverage for diagnostics, must there be a signed standalone order separate from the providers signed note indicating medical necessity and the request study?
A11: There does not need to be a stand-alone order, according to CMS IOM Publication 100-02, Chapter 15, Section 80.6.1. The publication goes on to state, "While the physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed."

Q12: What is the correct administration code to report for Leucovorin when administered concurrently with an antineoplastic drug as Eloxatin? CPT Assistant recommends 96368 but a retired local coverage article from Noridian (Billing and Coding: Chemotherapy Administration (A52953)) had Leucovorin listed as a chemotherapy drug. What is the correct way to report Leucovorin administration concurrent with an antineoplastic drug? Is concurrent administration of Leucovorin reported as a chemotherapy administration with 96569? Does it differ from the previous Noridian advice that states Leucovorin given with 5FU should be reported as chemotherapy administration rather than therapeutic drug administration?
A12: Chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services. There are some medications that are not chemotherapy but require more monitoring and therefore can be billed with the chemotherapy infusion code. Upon review by Noridian's CMD and Senior Clinic Reviewer and of clinical pharmacology and FDA, Leucovorin (J0640) is not considered a highly complex infusion, does not need extra close monitoring and can be billed with a therapeutic infusion code. Per CMS IOM Publication 100-04, Chapter 12, Section 30.5(E), "If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code should be reported." If Leucovorin is administered concurrently with a chemotherapy drug an add-on, therapeutic concurrent code such as 96368 should be used.

Q13: A beneficiary must be "under the care of a physician," as indicated by the physician certification of the PT plan of care. However, if a state has a direct access law to physical therapy, does a Medicare beneficiary require a physician/NPP's visit or referral prior to the Physical Therapist's initial evaluation? Or can the beneficiary self-refer to PT, receive an initial evaluation and development of a plan of care that can then be signed by the physician/NPP through a certification? If possible, can you please provide Medicare or regulatory references to support the answer?
A13: A beneficiary can self-refer and have an initial evaluation and work towards building a plan of care but needs to sign off before anything starts. It is not just the state that removed the order for physical therapy. See the CMS IOM, Publication 100-02, Chapter 15, Section 220.1.1 for more information.

Q14: Is there any official guidance when Medicare is not primary? For example, if there is a commercial payer and have the mandated sequence of modifiers that would apply to Medicare, but not the commercial payer. Where is the guidance that stipulates the billing or drives the billing when Medicare is secondary?
A14: Modifiers would be specified to each insurance company it is processed through and would be changed upon submission to secondary if needed. The provider would bill Medicare modifiers to Medicare.

Q15: If an authorization was not received from Veterans' Administration (VA), do we have to attempt to get authorization, or can they bill Medicare? What if the authorization was not obtained?
A15: Non-authorized services would be separately billable to Medicare. If you do have authorization from the VA, then all services should be billed to them. Per the CMS IOM Publication 100-02, Chapter 16, Section 50.1.1, Medicare does not pay for any item or service rendered by a non-Federal provider pursuant to an authorization issued by a Federal agency, under the terms of which the Federal government agrees to pay for the services. Where an authorization from the VA was not given to the party rendering the services, Medicare payment is not precluded even though the individual might have been entitled to have payment made by the VA had they request the authorization.

Succeeding the above question, the Noridian Webinars on Demand and Tutorial webpages were promoted.

Q16: Can a patient self-refer to a hospital-based acupuncturist or is a physician visit and signed referral/order by a physician required before the patient sees the hospital-based acupuncturist for acupuncture services?
A16: All types of acupuncture including dry needling for any condition other than chronic Low Back Pain (cLBP) are noncovered by Medicare. Patients will need to meet the requirement for cLBP, which is defined as: Lasting 12 weeks or longer, nonspecific (in that it has no identifiable systemic cause), not associated with surgery and not associated with pregnancy. Applicable ICD-10 diagnosis codes are in the attachment to CR 11755. A physician or NPP must evaluate and follow the patient with the usual therapies over a 12-week period. At that point in time, any of the providers with the credentials listed in the Acupuncture for Chronic Low Back Pain (NCD 30.3.3) may provide acupuncture services within the respective state scope of practice.

Auxiliary personnel furnishing acupuncture under the appropriate level of supervision of a physician, PA, or NP/CNS must follow all 'incident to' and other regulations outlined in 42 CFR 410.26 and 410.27.

Medicare expects that the servicing acupuncturist would perform due diligence to assure the 12-week duration of cLBP in spite of and adherence to good medical interventions to treat the back pain and that the beneficiary has been compliant with such care.

Q17: A patient is court-ordered to a facility for treatment. This is regarding the new software announcements on Medicare Advantage (MA) for incarcerated patients. Does the facility need to bill the MA plan first to receive a denial and then bill Medicare?
A17: Outlined under 42 CFR 411.4.b, patients who are required to reside in a mental health facility are patients that are considered incarcerated. According to the CMS IOM Publication 100-04, Chapter 1, Section 90, whoever is primary at admission is primary for the entirety of the stay. It will depend on exactly when the MA plan was termed.

Q18: Our facility has bundled the cost of most of our medications used, before, during, and after surgery; including antibiotics into our surgical procedure. However, we are still reporting the appropriate HCPCS codes and units on our facility claim for these medications with a token charge $0.10, but we are not receiving reimbursement. We understand we will not be reimbursed for status indicator (SI) "K" drugs if the surgical procedure code has an SI of "J1", but if the drug has an SI of "G", there is language that states " services on the claim are packaged with the primary "J1" service for the claim, except the services with Outpatient Prospective Payment System (OPPS) SI of "F", "G", "H", "L", and "U". From reading this, it means that if our drug has a SI of "G" and our procedure has an SI of "J1", then we should be receiving reimbursement for this drug. These are not the patient's own medications. The denial codes we are receiving are: CO-16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication and M54: missing/incomplete/invalid total charges.
A18: According to the Integrated Outpatient Code Editor (I/OCE) CMS Specifications, Effective July 1, 2021, drug HCPCS with final SI=G or K that are reported with charges less than $1.01 and at least $0.01 are line item rejected, unless a Line Item Action Flag (LIAF) of 2, 3, or 4 is present.