ACT Questions and Answers - January 20, 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.

Q1: In the CMS Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 50.3.2, CMS uses 12 hours of inpatient monitoring as an example, but do not  state if that is the maximum number of hours that can be reported or if it can be reported per day or encounter? Can you please clarify?
A1: Observation services must also be reasonable and necessary to be covered by Medicare. In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours. In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. This statement comes from the CMS IOM 100-02, Chapter 6, Section 20.6. Observation services are considered outpatient services.

Q2: When a home sleep study is performed and the interpretation takes place on a different date of service, should a provider  bill the technical (modifier TC) component separately on the date performed, and the professional component (modifier 26) on the date it was read? Or should providers bill the TC and 26 modifiers globally on the date the sleep study was interpreted?
A2: According to CMS MLN SE17023, The technical component is billed on the date the patient had the test performed. When billing a global service, the provider can submit the professional component with a date of service reflecting when the review and interpretation is completed and then submit the date of service as the date the technical component was performed. This will allow ease of processing for both Medicare and the supplemental payers. If the provider did not perform a global service and instead performed only one component, the date of service for the technical component would the date the patient received the service and the date of service for the professional component would be the date the review and interpretation is completed.

Q3: If a patient has two chronic conditions, do both chronic conditions have to be addressed each time that CCM services are provided throughout the month? Or can they address each condition at different times throughout the month if both conditions are addressed? Do the care managers have to address every chronic condition listed on the care plan or do they need to address a minimum of two conditions?
A3: Each condition would need to be addressed at some time during the month CCM is billed. It is not necessary to have all conditions addressed each time that CCM services are provided during the month. If the conditions may correlate and discussion or changes in the care plan may affect the other condition(s), it would be expected to see more than one condition discussed in the documentation for that CCM encounter. If the conditions are unrelated or the discussion would not affect the other condition(s), it would be acceptable to only see documentation at some point during the month for each condition indicated in the care plan. CMS has educational resources available: CMS CCM Services and CMS Connected Care Health Services: Chronic Care Management.

Q4: A claim paid for CPT 77290 provided on the date of service (DOS) 12/31/2019 was recouped due to 77295 being paid on DOS 1/6/2020, with denial reason code C7715. We have been unable to locate CMS guidance implementing this edit. The only reference found was the CMS indication they would consider implementing the edit, see If CMS has not implemented this edit, should Noridian by applying the edit?
A4: MACs were instructed internally by CMS to implement this edit based off existing policy.

Q5: Does the 91 condition code apply to services provided like the COVID-19 vaccine, COVID-19 antibodies, etc.? Do these types of services fall into this group? Does the 91 condition code replace the DR condition code for services being billed under the waiver?
A5: Condition code 91 should be reported on any approved Emergency Use Authorization (EUA) The 91 condition code becomes effective on 2/1/2021. The 91 condition code and the DR condition code are two separate condition codes, one is from the National Uniform Billing Committee (NUBC) and the other is from CMS. Additional information ca be found in CMS MLN SE20011 and MM12049.

Q6: Does the physician supervision rule for Cardiac Rehab and Pulmonary services allow for “General” supervision which would include audio-only telephone or text messaging during the PHE?
A6: According to pages 82-83 of the COVID-19 FAQ document, “…General supervision may also include a virtual presence through the use of telecommunications technology but we would note that even in the absence of the PHE general supervision could be conducted virtually, such as by audio-only telephone or text messaging”.

Q7: Our facility is receiving RAC denials based on unbundling edits when a patient has had a screening mammogram within three days of an inpatient stay. Noridian edits prevent us from bundling these services onto an inpatient claim dur to not allowing revenue code 403. Are mammograms completed prior to an inpatient stay are billable and reimbursable? If so, can these be reported on a 121 type of bill to receive separate payment?
A7: Mammogram services are subject to bundling. Please see CMS MLN SE1232 for more information.

Q8: Our facility has not received a Targeted Probe and Education (TPE) audit or an Additional Documentation Request (ADR) since the pandemic started. Can Noridian please clarify whether these audits have been restarted? In addition, can we check TPE and ADR requests in the portal now rather directly in DDE?
A8: MACs have not received direction from CMS to resume TPE audits. Currently MACs are conducting service specific claim reviews. More information can be found on Noridian’s Medical Review webpage under Post-Pay Reviews. Individual providers will be notified if they have an open, pending TPE file when we have direction from CMS to resume TPE activities. ADR requests for TPE and post-payment audits are available on the Noridian Medicare Portal within the Claim Status functionality with options to securely submit the requested documentation directly through the portal as a benefit to providers. More information is available on our website,

Q9. Please clarify if the JW modifier applies to skin substitutes; is a skin substitute considered a biological as nowhere is a biological defined? In CMS JW Modifier FAQ, question 18 specifies the JW requirement applies to items that are Status Indicator "G" or "K". Question 20 clarifies that the JW modifier is not used on items with Status Indicator "N". Skin substitutes are status indicator "N" and not separately payable meaning they are bundled into the Ambulatory Payment Classification (APC). Why then would facilities need to use the JW modifier on skin substitutes when they are status indicator (SI) - "N"? Staff are diligent to use the appropriate size and rarely would have any wastage.
A9: The JW modifier does not apply to drugs assigned status indicator “N” under the Outpatient Prospective Payment System (OPPS). Additional guidance is available in CMS MLN MM9603.

Q10: We are getting claims Returned to Provider (RTP'd) for Direct Data Entry (DDE) reason for M0239. We are reporting this infusion under 0450 and 0260 revenue codes. Per CMS's website, "On November 9, 2020, the U.S. Food and Drug Administration (FDA) issued an emergency use authorization (EUA) for the investigational monoclonal antibody therapy, bamlanivimab, for the treatment of mild-to-moderate COVID-19 in adults and pediatric patients with positive COVID-19 test results who are at high risk for progressing to severe COVID-19 and/or hospitalization." CMS FAQ, Sect. F, Q. 13 "CMS anticipates that monoclonal antibody products to treat COVID-19 will initially be given to health care providers at no charge." "Note, that Medicare pays for these monoclonal antibody products under the COVID-19 vaccine benefit...". Can you review this policy/FAQ question? A patient has to test positive for COVID-19 and be at high risk to receive this infusion. This is not a vaccine. Why is this under the vaccine benefit and rev code 0771?
A10: All COVID vaccines, including the monoclonal antibody administration code need to be billed with the A6 and 78 condition codes, Z23 and U07.1 diagnosis codes, and the administration code under revenue code 771. If the drug was received at no cost, do not report it at all.

Q11: CMS does not have its Diagnosis-related Group (DRG) pricer listed on the website and the Noridian Remittance Advices (RAs) do not give enough detail on amount to reconcile the DRG payment to factors. How can we get information from our respective hospitals? In the past, the Noridian "weight-of-one" spreadsheet was helpful.
A11: CMS is aware of an issue with the FY2021 IPPS web pricer in regard to entering a review code. The CMS IPPS PC Pricer  webpage has more detailed information and the link to access the 2021  IPPS Web Pricer. Over the next year, CMS will stop producing new versions of the downloadable PC pricers and issue them as web-based applications.

Q12: In regard to question 10, all COVID vaccines including monoclonal antibodies, is an antibody a treatment offered post-disease whereas a vaccine is provided pre-disease? When a drug received at no cost, providers are instructed to not report the drug at all? Does this mean Q0239 or M0239?
A12: For billing the drug at no cost; it is the actual drug itself, not the administration. It is a true infusion code, but it is covered under the preventative vaccine policy. The administration code for the infusion is billed on 0771 revenue code. This is the direction MACs received from CMS. CMS published a toolkit on the COVID-19 vaccine that provides direction for health insurance issuers and Medicare Advantage plans.

Q13: We are an ESRD facility with many throughout the country and bill on a 72X claim. There would be no other diagnoses on the claim. We will be offering the antibody treatment. We plan to offer this on a non-treatment day. Does CMS expect this to coexist with the dialysis treatment on that day? Our intent is treating one thing at a time and is hoping to avoid billing issues. We have been told when calling other MACs that the vaccine and antibody items should all be on one claim.
A13: These should be billed separate from the ESRD claim but they can occur on the same date of service. Noridian is unaware of any tests to ensure there is no interference. The COVID-19 vaccines and antibodies need to be billed with the applicable Z23 diagnosis. U07.1 is for the antibody treatment. The 78 condition code should only be appended to beneficiaries who are Medicare Advantage beneficiaries for whom providers are billing fee for service. The A6 for the vaccination code is still needed. CMS directs that bills for the antibodies and vaccines shall be separate from the ESRD claim. If a renal dialysis facility needs to report a drugs that is furnished to an ESRD beneficiary that was not related to the treatment of ESRD, they must include the AY modifier to indicate the item or service is not for the treatment of ESRD. This is stated in the IOM 100-04 Chapter 8 Section 50.2.5.

Q14: For the new value code for reporting renal limits, V6, is it only for hemodialysis and not peritoneal dialysis at home, correct? The dialysis machines talk to a cloud-based system and nurses can see how many minutes they were on their machines, even at home.
A14: The original proposed requirement was initially going to be for true hemodialysis under revenue code 0821, not including peritoneal dialysis billed on revenue codes 0831, 0841, or 0851. However, CMS has issued CR 12011, and it states CMS is withdrawing the requirement for ESRD facilities to report the value code D6 for the total number of minutes of dialysis provided during the billing period and reporting of the D6 value code is not required for CY2021.

Q15: Is giving antibody monoclonal and polyclonal vaccines and administration along with regular chemotherapy or with IVIG treatment allowed for the same date of service but billed on separate claims? Is it like the dialysis question and the bundling question?
A15: Noridian would look to the doctors to ensure it is safe to administer during the treatment. There are no concerns with billing currently. The monoclonal antibodies for COVID can be billed on a separate claim 72X TOB. If is it a regular chemotherapy treatment, infusion, or IVIG treatment, it should be included on the normal 72X TOB with the AY modifier.

Q16: For the AY modifier on fee-for-service and Medicare Advantage claims, when the vaccine or antibody is billed, would the A6 condition code and AY modifier be billed too?
A16: If the drug was provided and a cost was incurred, then yes, the drug would need AY if unrelated to ESRD. If the drug was received free of charge, do not report the drug at all. The AY modifier is not reported on the administration. The A6 condition code is for influenza traditionally, but all MACs are looking for this on COVID-19 vaccine claims to be covered as a preventive service.

Q17: Every time there is one of the diagnoses codes included on the noncovered list for a chest Xray, the claim is denied. Although there are other diagnoses included that would be covered, do all cases need to be appealed individually?
A17: If your claim contains one of the diagnosis codes on our noncoverage article, it was denied historically. The article has been updated and our system will read and deny if the noncovered diagnoses are in the first, second, or patient reason for visit (PRV) diagnosis slot. Individual appeals will be needed per claim.

Q18: Can a respiratory therapist provide counseling for tobacco addiction on their own with a physician order? There is discussion regarding “incident-to”, but how does this apply in a hospital outpatient setting?
A18:  Per the August 25, 2010 Decision Memo for Counseling to Prevent Tobacco Use, CMS can only cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries furnished by a qualified physician or other Medicare-recognized practitioners. Certified tobacco cessation specialists, pharmacists, registered nurses, chemical dependency counselors, health educators, and respiratory therapists are not recognized in the law as qualified Medicare Part B practitioners for furnishing counseling services. In the case of pharmacists, these health professionals may qualify as durable medical equipment suppliers for Medicare beneficiaries, but this type of Medicare supplier is not recognized as a qualified provider or supplier of counseling services.

Q19: Noridian had processed the 87636 lab test with a patient responsibility and cost sharing but it should have been paid at 100%. These have been processed properly more recently. What will be done with the previously processed claims? Will Noridian do a mass adjustment or does the provider need to adjust?
A19: Per SE20011, all services that are COVID related should be reported with the CS modifier. If these were submitted appropriately with the CS modifier, contact the provider contact center. If the provider did not have the CS modifier, they may attempt to update the claim as an adjustment. The quarterly update for January I/OCE indicates CPT 87636 is not applicable to cost sharing.

Q20: For question four, as to why CMS was pulling that back is that the MACs were instructed by CMS to implement the edit of the existing policy. What policy was used? We have had a few scenarios with payment issues and are aware there had been a policy regarding one modality not being covered, but we continue to have challenges locating the policy for other modalities available.
A20: Under CR9549, the billing instructions for IMRT planning state: Payment for services identified by CPT codes 77014, 77280, 77285, 77295, 77305 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT Planning). These codes should not be reported in addition to CPT code 77301 when provided prior to or as part of the development of the IMRT plan.


            Last Updated Tue, 13 Dec 2022 20:47:58 +0000