ACT Questions and Answers - April 14, 2021

The following questions and answers (Q&As) are cumulative from the general Part B 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 this directly with the provider. This session included Medicare program updates, pre-submitted questions, and questions posed during the event.

Duplicate Claim/Form Guidance for Providers

Medicare contractors cannot override or bypass exact duplicate edits in the claims processing system. To reduce the number of duplicate denials in your practice, please review these suggestions to improve billing practices and avoid denials.

  • Wait until remittance advice received by your office to ensure claim finalized before correcting claim, rebilling claim, or submitting appeal of what you anticipate as a denial.
  • Talk with billing agencies, clearinghouses, and your vendors to only auto-rebill claims after 30 days and ensure they are not resubmitting your claims after 14 days.
  • Use applicable repeat modifiers (76, 77, or 91) when repeating procedures or lab services.
  • Utilize the Noridian Medicare Portal (NMP) to check claim status and patient eligibility prior to claim submission.
  • When sending Medicare questions/forms/appeals and general correspondence (even for Medicare Secondary Payer-MSP), Noridian has 45 days to respond. Providers are asked to not continue sending duplicate inquiries or requests prior to the 45 days.
  • If submitting an appeal, secure submission through our NMP is the most timely and preferred method. Do not submit the same appeal through multiple submission methods such as NMP, postal, and fax submission.

Additional information can be found in the CMS Internet Only Manual (IOM) Publication, 100-04, Chapter 1, Section 120 “Detection of Duplicate Claims”.

Q1. We have a non-physician practitioner (NPP), not employed by our facility, and collaborates with a physician in private practice that rounds at the Skilled Nursing Facility (SNF). Can an NPP bill under a supervising physician in a SNF setting to perform subsequent visits for a nephrology group?
A1. No. Incident to does not apply to SNF services under §1861(s)(2)(A) of the Act. The NPP must enroll and bill directly to Medicare. In the SNF setting, an NPP enrolled in the Medicare program and is not employed by the facility, may perform physician tasks, and submit claims under their NPP billing number when the state law permits and working under collaboration with a physician. However, for SNF patients who are in a Medicare covered stay, there is no Medicare Part B coverage of the services incident to physicians’ services under §1861(s)(2)(A) of the Act. Read more in CMS Internet Only Manual at IOM 100-02, Chapter 15, Section 60.

Q2.  Will Low Dose Computed Tomography (LDCT) scans, at non-registry sites, be denied automatically by Medicare and would these count as “screening” for CPT 71271? What if the patient doesn’t meet the criteria (i.e., older than 77 years)? Do we bill 71271 or 71250?
A2. CPT 71271 is the new CPT code for 2021. Sites that are not registered will have claims for CPT 71271 denied. Likewise, if the patient is not eligible, providers cannot bill for the LDCT. More information may be found under Noridian’s Browse by Topics, Preventive Services, under Lung Cancer Screening. CPTs 71250-71270 are diagnostic and not to be used for screening.

Q3. CPTs 92603-92604 (Cochlear fitting) are denied when a patient is on a home health agency (HHA) plan. Home health is not involved as the patient comes in on their own. Is there any way to have these covered or do we just deny these patients services while in home health?
A3. No. For individuals under a home health plan of care, payment for all services (nursing, therapy, home health aides and medical social services) are included. Routine and non-routine medical supplies, with the exception of certain injectable osteoporosis drugs, Durable Medical Equipment (DME), and furnishing negative pressure wound therapy (NPWT) using a disposable device, is included in the HH Prospective Payment System (PPS) base payment rates. HHAs must provide the covered home health services (except DME) either directly or under arrangement and must bill for such covered home health services.

Q4. Since Licensed Master of Social Workers (LMSWs), Master of Social Workers (MSWs) and a Licensed Clinical Psychologist (LCP) cannot work “incident to” a Licensed Clinical Social Worker (LCSW) for psychiatric diagnostic evaluation (CPT 90791), can we bill this same comprehensive assessment towards Behavioral Health Integration (BHI) or Collaborative Care Model (CoCM)?
A4. Depends. Only if the BHI and CoCM have an MD or NPP supervising, and the clinical staff must meet the “incident to” rules. BHI and CoCM have their own rules that start with the beneficiary providing permission to the provider to assess and providers can read more at Behavioral Health Integration (BHI) MLN Fact Sheet-March 2021.   

Q5. Please compare “Analyzed” and “Independent Interpretation” in the Amount and/or Complexity of Data to be Reviewed in the Medical Decision-Making (MDM). Tests that do not require separate interpretation (e.g., tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level.
A5. The independent interpretation would include when tests are ordered and assumed to be analyzed when the results are reported. When they’re ordered during an encounter, they are counted in that encounter. Any service for which the professional component is separately reported by the physician or other qualified health care professional, reporting the E/M service is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM. Read more in the American Medical Association (AMA) published errata that includes an analyzed independent definition found at AMA Errata and Technical Corrections - April 2021.

Q6. Please compare “Reviewed” and “Analyzed” in the Amount and/or Complexity of Data to be reviewed in the Medical Decision-Making (MDM). Also, the same for “Reviewed” and “Independent Interpretation”. How does CMS interpret and apply AMA’s definition of “Analyzed”?
A6. A review is a formal assessment or exam, with the possibility or intention of instituting change, if necessary. CMS has not provided direction to indicate any differences from the AMA definition of “Analyzed”.

Q7. When considering the Medical Decision-Making required for Transitional Care Management (TCM), should the 2021 MDM table be utilized to determine the moderate or high complexity?
A7. Nothing has changed in the way provider would select these codes, as they are not affected by the 2021 E/M guidelines changes.

Q8. Can Noridian show how the new 2020 Positron Emission Tomography (PET) cardiac myocardial perfusion codes, 78429-78433, were carrier priced?
A8. After meetings with national organization representatives, Noridian will adjust several contractor-priced PET scan codes. The adjustments made to these codes are retroactive to January 2020 and any underpaid services will be reprocessed. Any overpaid services will need to be recouped. The correct fees are now posted to our website under Fee Schedules, Contractor C-Status pricing.

Q9. Can CPT 93793 (anticoagulation management for patients taking warfarin monitoring; includes physician review and interpretation of home, office or outpatient international normalized ratio-INR test result, patient instructions, dosage adjustment as needed and scheduling of additional tests when performed) be billed as a face-to-face (F2F) patient clinic visit, if that’s the only reason for the patient visit? How about when an Evaluation and Management (E/M) service is also billed?
A9. 93793 cannot be billed the same day as E/M CPTs 99202-99205, 99211-99215, 99241-99245 or during Chronic Care Management (CCM) or Transitional Care Management (TCM) calendar month service time. However, providers may bill the 93793 as a F2F visit, but not required. It’s only reported once per day regardless of number of tests reviewed.

Q10. If a patient is missing teeth and x-rays show radiolucency beyond the alveolar region, would removal of infected bone be covered?
A10. No. Most cases that are dental in nature are not considered a Medicare benefit. Please refer to Noridian’s Browse by Specialty, Dental page and the Internet Only Manual (IOM) Publication, IOM 100-02, Chapter 15 and 16.

Q11. The Consolidated Appropriations Act (CAA) of 2021, Section 123, requires behavioral health providers to have seen their client in person, during the prior six months, before a telehealth visit. Will this be covered by Medicare after the Public Health Emergency (PHE) ends?
A11. Yes. Per Section 123 of the CAA titled “Expanding Access to Mental Health Services Furnished Through Telehealth”; before a telehealth visit is covered, the beneficiary must have been seen within the six (6)-month period prior.

Q12. When a lab claim is denied, because the diagnosis does not meet medical necessity per the Local Coverage Determination (LCD) or National Coverage Determination (NCD), can an ordering provider fill out a form with additional diagnosis that pertains to that order, test and date of service? What documentation or chart notes will Medicare accept as an official form for a lab to add a diagnosis (provided by the ordering provider) to the denied claim for a reopening?
A12. If a provider is just adding a diagnosis, and it’s supported in the documentation by the ordering provider, a reopening may be sufficient. Make sure that a diagnosis was not added just to have the claim allowed. If a provider wants to suggest any updates or changes to LCD/NCDs, they must go through the “LCD Reconsideration Process” located under Noridian Policies, with supporting literature. This is not to be used for individual claims.

Q13. When a CPT is denied as contractual obligation (CO-236), under National Correct Coding Initiative (NCCI) and the other CPT with a lower fee schedule amount is paid, are we compliant to reverse the CPT that was paid and bill the CPT with the higher fee schedule amount? If so, do we need ordering provider chart notes or any other documentation?
A13. No. Providers cannot code based on reimbursement and must code on services provided. CO-236 states “This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the NCCI or workers compensation state regulations/fee schedule requirements.”Providers need to check NCCI code combinations before billing. If there are appeal rights, include all chart notes and documentation.

Q14. Polysomnography (PSG) sleep studies are denied for patients needing a new Continuous Positive Airway Pressure (CPAP) machine; especially if the patient has not been compliant. If there is no proof of the need, how can providers repeat the study?
A14. The repeat study should be covered after the explanation is provided. It can be confusing on the physician side if it’s unclear that the criteria was not met. Since the patient is noncompliant and must meet the terms of the Durable Medical Equipment (DME) supplier, patients may need the repeat study. That additional information is needed at the time of the claim, or appeal, and would be sufficient in the explanation for processing. There is a Part B/DME collaborative PAP/PSG webinar on May 26.

Q15. Behavioral health providers need to see their patients every six (6) months for telehealth services to be covered. Where is the CMS language that all license levels need to follow?
A15. Agree. The CAA, Section 123, requires all behavioral health providers to have seen their client in person during the prior six months before a telehealth visit is covered by Medicare. CMS extended Medicare payment for many services delivered via telehealth at least until the end of calendar year 2021.

Q16. Our podiatrist has a denial for CPT 97597 - debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps, open wound - fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less) with an ulcer diagnosis. There is no LCD for an ulcer debridement for diabetic patients and claims are primarily rejected by Medicare Advantage plans.
A16. Noridian cannot address or control how other Medicare Advantage plans are denying claims. The provider needs to work with their Medicare Advantage Plan and/or work with their CMS Regional Medicare office (in this case, out of Denver). All CMS offices have someone who specifically overviews the Medicare C plans and emails at CMS Regional Offices.

Q17. During the PHE, we billed place of service (POS) 11 for telehealth services. Should we begin to use POS 02 when the PHE is over?
A17. No. Guidance from CMS is the POS you normally would use, had the service been face-to-face. At this time, we have not received guidance from CMS to bill otherwise.

Q18. A physician provides more units of J1040 (methoprethozone) than the Medically Unlikely Edit (MUE) allows and all the J1040 units are denied, even on appeal with medical records. How should J1040 be coded on claims for reimbursement?
A18. J1040 (methylprednisolone acetate, 80 mg.). The National Correct Coding Initiative (NCCI), Chapter 1, Section V states, “If the MUE is adjudicated as a date of service (DOS) MUE, all units of service (UOS) on each claim line, for the same DOS for the same HCPCS/CPT code are summed, then the sum is compared to the MUE value. If the summed UOS exceed the MUE value, all UOS for the codes for that date of service are denied.” J1040 has a MUE Adjudicating Indicator (MAI) of “three (3)”, meaning a DOS MUE.

MUE denials can be appealed where payment is asked for units above the MUE value and reviewed by a clinical staff member. Therefore, it is recommended that documentation submitted should be legible, signed by the performing entity and support the medical reasonableness of the service(s) performed. MUEs associated with drugs (J codes) are typically set by the NCCI, based on the manufacturer’s prescribing recommendations or CMS-approved drug compendia. If your office is experiencing a large volume of MUE denials related to J codes, it is encouraged that verification of the correct units are being billed and appropriate dosing is administered by the provider.

Q19. How should we list CPTs on claims when notes and medical necessity support units over the MUE? For example: if 36 units of 11045 are supported, does Medicare want 36 units on 1 line, or split by MUE (12) on 3 lines with or without modifiers 59 or 76? Since we appeal, does it matter?
A19. Ultimately, it is up to the billing entity as to how they want to bill/submit their claim. However, from an appeal perspective, it is cleaner and more efficient if all units for the CPT/HCPCS are billed on one line, when the MAI is a two (2) or three (3).

Q20. Last year, the Noridian “Did You Know” section reflected J7999 (unlisted compounded intraocular bevacizumab) or Avastin was $94 as of September 2019. Where can I locate a published file with that reimbursement?
A20. Noridian does not publish our carrier-priced codes for unspecified codes. Continue to provide information in the comment/narrative (Item 19) section of your claim. While we are working on the publication of some of these codes as a process improvement, this has not been completed as of this publishing.

Q21. During the PHE, can a podiatry or footcare referral, required every six (6) months, be conducted via a phone or virtual conference instead of in-person?
A21. Yes. If the code is on the Telehealth list and the provider can fulfill all requirements of evaluating the patient via Telehealth, they should be able to perform the evaluation via Telehealth.

Q22. In order to be judicious in requests for national provider identifiers (NPIs) for all clinics in the areas they are located, their clinics are all under one NPI. There are no subspecialties reflected and this causes challenges to bill as a new patient for the different types of services their team members provided in different locations to patients. Can I have a contact with CMS to raise our concerns?
A22. CMS is aware of this issue. While we await a solution, providers may address at appeal or preferably reopening, for the sub-specialties issues affecting non-physician practitioners (NPP). If an NPP provides care incident to a physician (MD/DO), and the physician sees the patient at least part of the time, the physician may bill incident to for that visit with his/her NPI.

Q23. We have patients on dialysis and our provider does not provide dialysis services. Patients come into the emergency room (ER) for a transplant and we bill lab services. If the patient is receiving lab services while having dialysis End-Stage Renal Disease (ESRD), claims are denied for consolidated billing eligibility. We bill an AY modifier and indicate the services are not related. What is considered ESRD-related services for consolidated billing. (e.g., transplant, ESRD service and lab listings).
A23. Please visit these CMS websites that provide ESRD and Consolidated Billing resources.

Q24. Kyphoplasty is performed, the patient is in severe pain, and it’s the only pain relief. The provider does not have documentation of the patient neoplastic disorder or fracture, but insists the patient needs. Is there any appeals documentation to have services (e.g., wedge compression fracture, etc.)?
A24. Noridian suggests that the provider review the Local Coverage Determination (L34106 Jurisdiction F or L34228 for Jurisdiction E) for covered diagnoses and other requirements. If the provider wishes Noridian to consider updates, a formal LCD reconsideration may be requested.

Q25. Part A/B rebilling is performed in a case where the patient did not meet inpatient criteria. Our internal audit evaluates the admission date, time and pharmacy invoked on 121 and 131 TOBs. The second claim submitted is rejected as a duplicate and the pharmacy cannot have repeat modifiers. How can we have our claim allowed?
A25. Since this involves UB-04 billing, this would be best handled by calling your state jurisdiction Noridian Part A contact center, JF 877-908- 8431 or JE 855-609-9960.


            Last Updated Thu, 17 Feb 2022 18:10:10 +0000