ACT Questions and Answers - May 20, 2020

The following questions and answers (Q&As) are cumulative from the Part A 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. Regarding SE20016, updated April 30, 2020 for FQHCs, will the list of FQHC qualifying visits for the PPS payment codes be updated to include 99441, 99442, and 99443 (pages 4 of 7 - Additional Telehealth Flexibilities).
A1. Per CMS SE20016, effective January 27, 2020, RHCs and FQHCs must use G2025 to identify services that were furnished via telehealth. FQHC telehealth services billed between January 27, 2020 and June 30, 2020 with qualifying visit G-code, any distant site codes that describe services furnished via telehealth and modifier 95 and G2025 with modifier 95 will be paid at the Prospective Payment System (PPS) rate. However, these claims will be reprocessed July 1, 2020 and paid $92.03. There is no need for FQHCs to resubmit the claims.

Q2. Regarding SE20016, if the above codes will not be qualifying visits, then they are billable effective dates of service March 1, 2020 (pg. 4 of 7), but we hold them until July 1, 2020 and “bill them with G2025” (pg. 3 of 7), will the claim have just G2025 on it or both 9944X and G2025?
A2. Effective March 1, 2020 audio only services 99441-99443 were added. Providers can furnish and bill for these services along with HCPC G2025. Beginning July 1, 2020 providers may bill G2025 as a stand-alone telehealth visit; the 99441-99443 are included in the G2025.

Q3. What is the significance of the July 1, 2020 date? Since qualified visits (audio visual) are effective January 27, 2020 and audio only is effective March 1, 2020 (but must be held), we think July 1, 2020 is a technology implementation date for G2025 for FQHC claims, meaning that earlier dates of services, can be billed after July 1, 2020 using G2025. For example, (1) an audio-visual visit (qualifying) for date of service February 2, 2020 will need three lines before July 1, 2020 and just one line G2025 after July 1, 2020 or (2) an audio-only visit on March 1, 2020 must be held until July 1, 2020 and will also have just one line when it is billed.
A3. Beginning July 1, 2020 FQHCs will only be required to submit G2025. Based on the above example, any audio only services provided from January 27, 2020 through March 1, 2020 that are billed to Medicare before July 1, 2020 please refer to A1 (Answer 1). Providers may choose to hold choose to hold distant site telehealth claims and bill the G2025 beginning July 1, 2020.

Q4. As an organization, there is variation among us in the interpretation of SE20016. Some consider that if Medicare is allowing 9944X for FQHCs, that the PPS Specific Payment Code List will be updated to include these audio-only codes. Others feel that SE20016 states that the non-qualifying 9944X visits, which are newly allowed, are a temporary “Additional Telehealth Flexibilities” and will remain non-covered services billable only during PHE.
A4. Telehealth distant site services became effective January 27, 2020. CPT 99441-99443 codes were added to G2025 effective March 1, 2020. Any claims processed prior to July 1, 2020 will be reprocessed at the $92.03 rate. Providers may choose to hold choose to hold distant site telehealth claims and bill the G2025 beginning July 1, 2020. Claims billed on or after July 1, 2020 with the G2025 will not need to be reprocessed. The system won't be updated until July, which is the reason you can choose to hold these claims so they are correctly paid.

Claims will process according to the instructions in place at the time of submission. If changes are made to previous dates of service, CMS will indicate whether the providers will have to submit for a change in processing to the MAC or MACs will reprocess.

Noridian does not know how long CMS will continue the additional flexibilities. Per the CMS MLN Matters SE20016, “WHAT YOU NEED TO KNOW” section, "These changes are for the duration of the COVID-19 PHE, and we (CMS) will make additional discretionary changes as necessary to assure that RHC and FQHC patients have access to the services they need during the pandemic. For additional information, please see the RHC/FQHC COVID-19 FAQs at https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf.”

Q5. Please explain the proper use of COVID19 related modifiers CR & CS. When do we apply them? Which claim lines do we apply them to? Should we use both on the same line, if so which claim line and which modifier should be in the 1st position? Also, currently the Medicare claims processing system is not processing these claims properly. Any update on when this will be corrected?
A5. The “CR” (catastrophe/disaster related) modifier applies to Part B billing, both institutional and non-institutional claims (CMS-1500) as defined in the CMS Internet Only Manual, Publication 100-04, Chapter 38, § 10. The "CS" modifier (waives patient liability) applies to institutional claims, providers, including hospitals, CAHs, RHCs, and FQHCs. Payment modifiers are placed first on the line item. The “CS” modifier issue was resolved May 13, 2020. Please read the Alert on the Noridian website.

UPDATE: On June 01, 2020 SE20011 added a section on clarification on using the CR modifier.

Q6. Please provide coding/billing guidance on COVID related policies from an outpatient hospital perspective - CS modifier, therapy charge on a UB-04?
A6. Medicare pays for hospital visits performed remotely by hospital-based practitioners to Medicare patient registered as hospital outpatients including when the patient is at home when the home is services as a temporary provider-based department of the hospital. This includes therapy services. Providers may bill Q3014 in this circumstance, since the patient would normally at the hospital and the physician is at the distant site The CS modifier waives liability and is added to the line item on the UB-04 claim form.

UPDATE: On May 27, 2020 the FAQ added section FF. Outpatient Therapy Services billing instructions for outpatient hospital services. https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

Q7. Please clarify how to make a patient's home provider-based to the hospital during PHE?
A7. All hospitals that relocate excepted on or off-campus Provider Based Departments (PBDs) in response to COVID-19 PHE should notify their CMS Regional Office by email the following: CCN, address of the current PBD, address of the relocated PBD, beginning date of service, justification for relocation, role of relocation in response to PHE and attestation that relocation is consistent with state emergency preparedness or pandemic plan. Send within 120 days of furnishing and billing for services.

Hospitals do not need to submit an updated CMS855A enrollment form. To the extent that a hospital may relocate to an off-campus PBD that otherwise is the patient’s home, only one relocation request during the COVID-19 PHE is necessary.

CMS expects hospitals to include in their justification for the relocation why the new PBD location (including instances where the relocation is to the patient’s home) is appropriate for furnishing covered outpatient items and services.

Reference: Interim final rule with comment IFC pages 40-43.

Q8. Due to COVID19 epidemic, will CMS accept electronic fax(s) of Appeals/Medical Records?
A8. Yes. Noridian is still accepting Appeals/Medical records via the Noridian Medicare Portal (NMP), fax, mail and courier mail.

Q9. How many 96366 is it appropriate to charge in the case of IV infusions of the same drug that run separately?
A9. Per the April 1, 2020 MUE file, the MUE value for 96366 is 24. The Noridian Medicare website has an MUE Lookup Tool for provider utilization.

Q10. In coding as an example 99213 with 99497, would the modifier 25 be placed on the 99497? Are there specific guidelines?
A10. No. The modifier should be reported on 99213. Please see the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edits for specific guidelines.

Q11. With the [insulin] drug non-reimbursable by Medicare, would the hospital be able to charge for the administration of the insulin drug (i.e. CPT 96374 or 96375)?
A11. No. If the drug is not payable, then the administration of said drug is also not payable.

Q12. Please thoroughly provide information on how CR Modifier and DR condition codes are to be utilized on a UB-04 - inquiring if and what modifiers are needed for billing Psych and Rehab when Telehealth services are provided. Please provide clarification if G2012 is billable to Medicare on UB-04 claim.
A12. The “DR” (disaster related) condition code for institutional billing, i.e., claims submitted using the ASC X12 837 institutional claims format or paper Form CMS-1450. The “CR” (catastrophe/disaster related) modifier applies to Part B billing, both institutional and non-institutional claims (CMS-1500) as defined in the CMS Internet Only Manual, Publication 100-04, Chapter 38, Section 10. Yes, it is applied to all claims billed on the UB-04 based on Section 1135, PHE. A virtual visit (HCPC G2012) is billable using a broad range of communication methods for patient-initiated services. The patient must agree to the service at least once a year and is applied to new or established patients.

UPDATE: On June 01, 2020 SE20011 added a section on clarification on using the CR modifier and DR condition code. https://www.cms.gov/files/document/se20011.pdf

Q13. Do we need to seek an extraordinary circumstances relocation exception to consider a patient’s home a PBD? If so, how do we do that?
A.13 Yes. Please contact your Regional Office to apply. Reference: Interim final rule with comment IFC pages 38 and 41-42.

Q14. For outpatient services normally billed on the UB-04, such as PT, OT, SLP, etc., that are now provided via telehealth, can we bill those CPT codes that are on the telehealth list on the UB-04? For example, if we are providing PT via telehealth to a patient in their home, could we bill 97110 (on the telehealth list) on the UB-04?
A14. Telehealth codes can only be billed by independent therapist. Bill outpatient therapy services on UB-04 or CMS-1450 during PHE when the patient is at home. The patient must be registered as an outpatient. Make sure to use the correct condition codes and modifiers for the telehealth services.

Use therapy modifiers and the “DR” condition code and “CR” modifier which are mandatory for institutional and non-institutional providers in billing situations related to COVID-19 for any claim for which Medicare payment is conditioned on the presence of a “formal waiver” (as defined in the CMS Internet Only Manual, Publication 100-04, Chapter 38, § 10. Revised April 23, 2020 https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

UPDATE: On May 27, 2020 the FAQ added section FF. Outpatient Therapy Services billing instructions for outpatient therapy services can be reported with modifier 95 applied to the service line. https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

Q15. For audiologists and speech language pathologists, enrolled with Medicare, the CPT codes they provide are on the CMS Telehealth List but are not marked as Eligible Providers to provide telehealth. Is this an oversight? Can they perform services allowed on the telehealth list within their scope of practice via telehealth and bill for these services on a UB-04 or 1500?
A15. May 15, 2020 the latest update to the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers now allows independent speech language pathologist, physical therapist and occupational therapist to bill Medicare for telehealth services, on the CMS-1500 form. The telehealth service must include at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.

Q16. How does the hospital get reimbursed for a drug, not subject to consolidated billing, when in a SNF?
A16. The SNF is responsible for most of the resident's services in the Part A stay. The excluded services such as physician and certain other practitioners remain separately billable. Any Part A or Part B service that is subject to SNF consolidated billing, must be provided under an arrangement with the SNF. When the SNF does not identify services as being subject to consolidated billing when ordering services, both parties need to reach a common understanding on terms of payment. Reference: CMS IOM 100-04 Chapter 6 Section 10.4

Q17. Is the CR modifier required for all COVID-19 related services?
A17. SE20011 contains the guidance regarding using the modifier on the applicable services.

UPDATE: On June 01, 2020 SE20011 added a section on clarification on using the CR modifier.

Q18. Prior to COVID, ancillary services or service performed by hospital clinical staff services in a provider-based department of hospital was billed a G0463 (Hospital outpatient clinic visit for assessment and management of a patient or Hospital outpatient clinic visit). Today, that visit is being done remotely using audio/video. Would it be acceptable to bill Q3014 on UB or 99211 on 1500?
A18. Clinical support staff is still required to document the services and education provided to the patient during the visit. These outpatient hospital services are billed on the UB-04 using the appropriate CPT/HCPCS for the visit. Review Interim Final Rule to determine which type of audio/visual services provided for proper billing. Reference: Interim final rule with comment IFC

Q19. We are billing 77386 for complex for esophageal cancer and are receiving RTP claims within DDE. We do multiple sessions and bill the sessions at the end of the treatment. The plan may incorporate multiple days which also include physician services which may use a diagnosis, the claim is rejected for prostate or breast service not related to the IMRT treatment.
A19. Noridian will terminate this edit coinciding with the retirement of the Local Coverage Determinations for Intensity Modulated Radiation Therapy (IMRT) and Policy Articles and enable the Radiation Oncology Model. Noridian will review the usage data for diagnoses, frequency and cost over the next 6-12 months and reassess the need for an LCD.

Q20. If RHC/FQHC hold claims until July 1, the claim will process with a $92 reimbursement instead of AIR with a take-back?
A20. Claims prior to July will be paid the AIR and then adjusted to the $92.03. Clams submitted after July will have the proper reimbursement.

Q21. I would like to ask about claims with MolDx and the difficulty in having the correct C-codes. I understand Palmetto updates this frequently but we still experience challenges with claim submission. Will there be consideration to have this removed and allow providers to submit directly to the MAC?
A21. Noridian collaborates with Palmetto on workgroups and will bring your concern to the group. The PCC may be able to assist with the claim-specific issues with Return To Provider (RTP) claims.

Please follow the guidelines on the Noridian Medicare website for Molecular Diagnostic Services (MolDx) to determine the appropriate Z-code.

Q22. Are we also supposed to register all patients with the regional office as an alternate site to our outpatient department?
A22. Contact your CMS Regional Office. CMS expects hospitals to include justification for the new physician-based location including the patient’s home is used for covered outpatient services. Hospitals do not need to submit an updated CMS855A enrollment form. To the extent that a hospital may relocate to an off-campus PBD that otherwise is the patient’s home, only one relocation request during the COVID-19 PHE is necessary. Reference: Interim final rule with comment IFC pages 38 and 41-42.

Q23. Are you able to bill Q3014 with telephone only codes with 99441-99443 when patient is located at home?
A23. No.

            Last Updated Thu, 11 Jun 2020 19:34:51 +0000