Article Detail - JF Part A
ACT Questions and Answers - March 22, 2023
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
- CMS Website: CMS has changed the look of its website. All the information remains easily accessible.
- 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: Can you advise if Critical Access Hospitals (CAHs) should follow Correct Coding Initiative (CCI) guidelines for ancillary services provided in the inpatient setting? The OCE is specific to outpatient claims but since CAHs are paid by cost, I would like clarification if the CCI edits do or do not need to be followed when billing for inpatient ancillary services (radiology, labs, RT, etc.) specifically CPT 94640. The CPT book advises "for more than one inhalation treatment performed on the same date, append modifier 76", but NCCI Policy manual for Medicare specifically indicates in the outpatient setting 94640 can only be billed once per encounter. If a patient with respiratory condition is admitted, our hospital can do many units of 96460. In our case, we would be reimbursed for all of them since we are paid on cost and the CPT codes are not present in inpatient bills.
A1: NCCI edits do not apply to inpatient claims. Hospital Procedure to Procedure (PTP) edits are applied to Type of Bill "85X, and OPPS flag = 2" and is explained in the narrative in the Outpatient Code Editor (OCE) Quarterly Release Files and in the MLN article SE18012
The MLN Educational Tool, How to Use the Medicare National Correct Coding Initiative (NCCI) Tools, provides more information.
Q2: What are the correct dates we should have in the "from" and "through" dates on the UB04 form field box 12? Should this date represent the first date of service from and discharge date or should it represent the admit and discharge date regardless of if this patient was in the ER the day before the admit order was written?
A2: The From date represents the first date of service which would include an ER visit the day before. A valid "from" date could be up to and including three-days (or a one day) prior to the actual inpatient admission based on the three-day/one-day payment window.
Q3: Our facility has a question regarding billing the standard cataract lens when a specialty lens is placed. We understand Medicare covers the standard conventional cataract lens (V2632), however, is it appropriate to report both the covered lens (V2632) and the non-covered lens on the same claim when only the specialty lens is inserted? We realize the V2632 would be reported in the covered column and the non-covered lens be reported in the non-covered column and the patient responsible for the difference between the two lenses. CMS guidance addresses Ambulatory Surgical Centers and office settings; however, our question relates to billing hospital OPPS outpatient and Critical Access Hospital Outpatient.
A3: The CAH would bill for cataract surgery (i.e., 66984, 66982, etc.), for non-covered lens, bill V2787 to report the non-covered A-C (Astigmatism-correcting) Intraocular lens (IOL) functionality charges of the inserted intraocular lens. Note: while V2788 is no longer valid to report non-covered A-C IOL charges, it's valid to report non-covered P-C (presbyopia-correcting) IOL charges. CMS will pay CAHs method II claims under current payment methodologies for conventional IOLs.
Q4: The Medicare Benefit Policy Manual Chapter 13 §40.1 states RHC and FQHC visits may not take place in an inpatient or outpatient department of a hospital, including a CAH. Services furnished to patients in any type of hospital setting (inpatient, outpatient, or emergency department) are statutorily excluded from the RHC/FQHC benefit and may not be billed by the RHC or FQHC. We frequently have RHC providers see patients in inpatient, observation, and outpatient encounters. Most often it is our obstetric patients who are seen for complications, sometimes requiring only a short outpatient visit but could also be held for longer observation and eventually admitted as inpatients. Are these visits by our RHC providers billable with a revenue code 0982 or is it the fact the providers are RHC providers that they are not allowed to bill for these services at all?
A4: No, the RHC cannot bill for a visit and or service in a statutorily excluded setting.
Q5: Is it appropriate to report code 77470 - Radiation special treatment procedure for the additional physician management of a patient receiving oral chemotherapy such as temodar or xeloda?
A5: 77470 is a radiation code and is intended to be used in combination of other radiation treatment codes.
Q6: During a Noridian physical therapy review, we received a coding error because we reported 97542 for a wheelchair fitting and adjustment, rather than 97162 - physical therapy evaluation. Our understanding is that a physical therapy evaluation would be included in the code for 97542. When is it appropriate to report 97542 - Wheelchair management versus 97162 - physical therapy evaluation when a wheelchair fitting and adjustment is involved?
A6: In general, the 97162 is the best basic assessment for the criteria of the wheelchair (or possible other device) use, while 97542 is the training to use the wheelchair once it has been assigned and obtained. Review your coding error for additional information.
Q7: The planned procedure was a coronary artery bypass graft (CABG), and the patient was taken to the OR and anesthesia was administered. After a transesophageal echocardiogram (TEE) was performed the CABG procedure was aborted due to patient's condition. Provider felt the patient would need extracorporeal membrane oxygenation (ECMO) to come off the pump. The patient was sent home, so, no admission occurred. The claim place of service was outpatient. We do have revenue code 360 charges, so, we coded the planned procedure of the CABG 33517 and 33533 both with modifier 74. The claim was denied as these codes are both inpatient only procedures. How should this be filed? Should we only code TEE codes with Revenue code 360?
A7: In general, we can say that it is inappropriate to bill two inpatient-only codes as outpatient. Also, modifiers 73 and 74 are modifiers specifically for Discontinued Ambulatory Surgical Center (ASC) and outpatient hospital claims so it would be inappropriate to use those modifiers on inpatient-only codes as well. If a patient is under inpatient orders and the surgery begins, it would also not be appropriate to bill the claim as outpatient as the orders reflect as inpatient. Noridian recommends reaching out to your specialty associated such as the AAPC for more specific claim submission guidance for discontinued inpatient surgeries.
Q8: My question is on leadless pacemakers and Coverage with Evidence (CED). I do not see a coverage article that has updated CPT codes for the implants, removal/replacement, programming, or interrogation. Do we need to continue to apply the Q0 modifier and other CED required codes for removals, interrogation, and programming? I can see that we need to for initial implant, but the information still lists the category III codes. It is not clear if there has been an update to each of the services.
A8: Yes, you will need to continue to apply the Q0 modifier and other CED requirements for removals, interrogation, and programming. We are reaching out to CMS regarding the outdated coding in the NCD and IOM.
Q9: If a patient was Observation Patient Class for medically necessary condition, and during the stay has an interventional procedure, does the facility need a new order for observation post the surgical procedure to report observation hours, or does the facility simply subtract the standard post op recovery time before reporting observation hours again?
A9: No, a new observation order is not needed. Observation services should not be billed along with diagnostic or therapeutic services for which active monitoring is a part of the procedure. In situations where such a procedure interrupts observation services, hospitals may determine the most appropriate way to account for this time. 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 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.
Q10: If a patient is in same day surgery patient class for a medically necessary condition, has the scheduled surgical procedure, has a post op complication in one hour recovery time, where the condition prompts the provider to write an order for observation patient class at that time. Does the facility subtract the standard six hours post op recovery time, after the surgical procedure is completed before billing new observation hours?
A10: Observation services must be patient specific and not part of the facility's standard operating procedures. If observation is required after an outpatient surgical procedure and the patient meets criteria for observation monitoring after the standard surgical recovery period, you can place the patient in outpatient observation; however, the observation care will be bundled into payment for the surgical procedure.
Q11: For all observation hours that are past the initially covered 48 hours, it has been the instruction of Noridian to place the non-covered hours in box 48 on the UB04 with instructions that one line should be REV code 0762 HCPCS G0378x 48 hours. Second line under REV code 0762 with whatever the overage of the covered 48 hours is. Could you clarify if the second line has HCPCS G0378, or should it have no HCPCS, just REV code and hours?
A11: Report all services rendered while the patient is in observation with the appropriate revenue codes, HCPCS/Current Procedure Terminology codes, and diagnosis codes. If a period of observation spans more than one calendar day, all the hours for the entire period of observation must be included on a single line and the date of service for that line is the date that observation care begins.
Q12: RHC providers seen in the hospital on an outpatient status. When they see patients in an observation setting(admitted), can they charge for a visit in a hospital?
A12: No, that's not a place they can statutorily provide services as a practitioner. They can't provide service in a hospital setting, even in observation status.
Q13: Does Medicare Advantage follow the Medicare guidelines for inpatient billing, specifically the three-day rule?
A13: Medicare Advantage follow the same basic guidelines, but, have different rules and regulations that govern them. We would have to direct that question to the Medicare Advantage plan.
Q14: Is there a list of HCPCS codes for non-covered services?
A14: MLN906765 - Items & Services Not Covered Under Medicare
List for covered services: Specific Payment Codes for the Federally Qualified Health Center Prospective Payment System (FQHC PPS)
I/OCE Quarterly "Data" Files include a list of services: I/OCE Quarterly Release Files
Q15: For the OC quarterly release tabs, is it specific for all providers or only FQHC?
A15: IOCE Quarterly Data Files is not specific to FQHC , however, the FQHC section is 5.22
Q16: Can you clarify if the G0480 amount can change based on what metabolite we test or is it a fixed charge?
A16: This is priced off the clinical lab fee schedule and would price based off what CMS has published. For questions about those fee schedules see: 23CLABQ1
Q17: Regarding PHE (when no longer in effect on May 11) Will there be no telehealth services allowed or will there be a modified list for hospital outpatient departments? Is it all going away, or just some?
A17: After the PHE, there are a variety of different circumstances for different providers. Look on the CMS website under their COVID listings with fact sheets that are individual to most off the different provider types, include physicians, labs, RHCs, etc. If you look at those, they'll give you more specifics regarding what services will be available, and for how long. We highly encourage you to look at this. We do have some upcoming webinars.
Q18: I have a question about specific LCA A52966. We had a couple claims deny by Medicare. We couldn't understand the reasoning. We called our intermediary, and we were told the code from the LCA was Line #4, PCS code line #1 was coded on line #5. Because they were not on the same line, that is why our claim was denied. To get the plan processed for payment, we would need to go through the Appeals process. I wasn't understanding why they are looking at a line item. The codes came from group 1 and the group one code. It should have been covered.
A18: While we are aware of one code that is not processing correctly, we are in the process of having the correction made. Without being able to see your claim, we are not able to provide more specific information for you. Our Provider Contact Center (PCC) is your best avenue to pursue this as they can look at the claim with you.
