ACT Questions and Answers - May 15, 2019

The following questions and answers (Q&As) are cumulative from the 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. Due to an unfortunate technical difficulty with the webinar reports following the event, the below includes the pre-submitted Q&As only. Providers are encouraged to call the Provider Contact Center (PCC) with questions. Noridian sincerely apologizes for any inconvenience.

Q1. An initial claim has been billed and the facility received a denial due to medical necessity/additional documentation, such as signed progress notes. If it is the first time to appeal, can an Appeal/Redetermination request be submitted using the Noridian Medicare Portal (NMP)?
A1. Yes.

Q2. A patient, admitted to a Critical Access Hospital (CAH) Swing bed, has a procedure at another facility on an outpatient basis. Can those services be billed to Medicare by the other facility? If the patient spent the night at the other facility and was on a leave of absence from the CAH, is the answer the same?
A2. No. The services are part of the inpatient care received at the CAH Swing-bed. If the patient is out of the CAH Swing-bed over the midnight hour, a leave of absence must be billed, and the other facility can bill for the services.

Q3. Within the ED, can CPT 96365 be charged when insulin is given as a continuous IV drip that runs for more than 16 minutes? Can CPT 96374 be used for IVP insulin in the ED? It is listed as a Self-Administered Drug (SAD) but it seems these cases should be chargeable?
A3. No form of insulin, regardless of the route of administration, is reimbursable by Medicare. Insulin is a "usually self-administered" drug per the CMS instructions for determining the definition in the Internet Only Manual (IOM).

Q4. When the physician orders observation services, there is no medical necessity. Are we still required to follow the order? Another hospital is quoting Medicare in saying we can't not follow the physician's order and must post observation charges. Is it acceptable to ignore the physician's order for observation and not post charges? If there is no medical necessity, is it okay that we post observation charges for productivity purposes and just make sure that the observation charges are not present on the claim?
A4. It is the patient's condition, at the time of admission, that dictates the appropriate setting.

Q5. When is it appropriate to use revenue code 0164? The definition states sterile environment. When do we use Isolation vs a Private Room revenue code? In the IP Admit order, the physician selects med surg. Later in the patient's stay, a patient care order is placed for isolation (i.e., contact precaution, standard precaution, C diff, MRSA nares or sputum, VRE Urine, ESBL wound or urine). Is it appropriate to change the room charge from med/surg to isolation? Or is isolation limited to negative airflow rooms?
A5. All isolation rooms must have negative pressure. A patient can be changed from a med or surg room if he/she presents conditions that may compromise their immune system or if they have developed a contagious disease. Private rooms are typically selected by the beneficiary or family, and if there is no medical condition that requires this setting, the beneficiary is responsible for payment.

Q6. Clarification needed on FL 52.

  1. This is considered a required field. Does that mean the claim will deny if FL 52 is blank or will either of the indicators "I" or "Y" trigger a denial?
  2. Do providers/organizations have to vet a signature authorizing release of information for every encounter or episode of care?
  3. Our facilities are HIPAA covered entities; and are not required to obtain a signature to release information for claims payment. Do the HIPAA guidelines conflict with the FL 2 signature requirement?

A6. Consent refers to patient approval for disclosing PHI for treatment, payment, and health care operations or other reasons that do not require authorization. The HIPAA Covered entities are not required to obtain consent. However, for covered entities that voluntarily do so, it is best practice to follow internal procedures accordingly even if that requires obtaining a patient signature. Form Locator 52 refers to the Release of Information Certification rather than consent and is a required field for claims processing.

Q7. When T45.1X5A diagnosis is on a claim with the EA modifier appended to J0881/J0885, we have been seeing claim denials on them. Per the National Coverage Determination (NCD) 110.21, diagnosis T45.1X5A is not allowed with modifier EC but there is nothing in the NCD stating it can't be used with EA modifier. Is there a different reference? Why are we receiving these denials?
A7. This is currently being researched. If warranted, a mass adjustment will be completed on all affected claims.

Q8. In the most recent update to the Chemotherapy Administration LCA (A52991) it states, HCPCS J0640 can be reported with a chemotherapy IV administration only when billed with 5-luoroacil. In the January 1, 2019 revision history information, it states "Added J0640-leucovorin calcium to have IV chemo admin codes payable when given with 5-Fluoracil…" "given with" and "with" have two different meanings. How should a provider bill for leucovorin when given to a patient while he/she is at a facility and the 5-luoroacil is given in an infusion pump over 48 hours while the patient is at home? It appears that this situation meets the policy that leucovorin is "billed with 5-fluoracil" (both are billed on the same date of service on the same claim). Does this situation meet the "given with" statement in the revision history information?
A8. If the leucovorin is given on the same date of service the 5-luoroacil is started, the HCPCS J0640 is payable with the chemotherapy administration code. Both codes must be billed on the same date of service.

Q9. In retired Erythropoiesis Stimulating Agents (ESA) Local Coverage Determination (LCD), there was specific criteria for coverage which included myelodysplastic syndrome (MDS) in symptomatic patients. In the policy, it stated both the anemia code (D63.8) and the code for the condition (D46.X) are required on the claim. Recently, when following these guidelines for our MDS patients, we have seen an increase in denials for HCPCS J0885 and J0881. Is MDS considered a cancer or related to a neoplastic condition? Would we then be required to follow NCD 110.21? Can any guidance be provided on correct coding or guidelines?
A9. Issues with the EC modifier has been fixed and a mass adjustment will be completed for incorrectly processed claims. The EA modifier is currently being researched by Noridian.


            Last Updated Tue, 09 Jul 2019 10:33:35 +0000