ACT Questions and Answers - March 18, 2020

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

Q1. Does the Medical Documentation 2020 Final Rule mean a mid-level provider could; a) document all elements of a note; then the MD reviews, verifies, and bills under their national provider identifier (NPI) or b) mid-level providers are now allowed to review and verify notes like MDs?
A1. It means when furnishing their professional services, clinicians (meeting incident to requirements) in all settings may review and verify (sign/date) notes in a patient's medical record made by other physicians, residents, nurses, students or other members of the medical team, rather than fully re-documenting the information. More information can be found on the CMS website under Simplifying Documentation Requirements. CMS has also provided several updates in Summary of Policies CY 2020 and Documentation Requirement Lookup Service Initiative.

Q2. A Skilled Nursing Facility (SNF) is refusing to pay for physician services provided during a Part A covered stay. Is it possible to have someone contact the SNF to provide education on their responsibilities?
A2. If the SNF refuses to pay, providers may call the Part A Contact Center to inform the SNF about the situation. The SNF needs to bill Medicare for virtually all the SNF resident's services received during a covered Part A stay. Under the consolidated billing requirement, the SNF itself should bill. The absence of an agreement does not relieve the SNF of their overall responsibility to furnish directly or under arrangement for all services that are subject to the consolidated billing requirement. On the other hand, if the physician is billing a Part B service, such as a medical visit to the patient, the physician can bill Part B. More information can be found on the CMS Consolidated Billing, along with Best Practice Guidelines-2019 and Change Request (CR) 11381-SNF Consolidated Billing (CB) Enforcement.

Q3. Can a Registered Nurse First Assistant (RNFA) assist a supervising surgeon in surgery for a Medicare patient?
A3. No. RNFAs are not recognized Medicare providers. The RNFA can perform the service; however, even under "incident to" rules, they are not able to have their time allowed separately. If the RNFA is employed by the hospital, Part A payment would include that ancillary staff. The only providers that can assist at surgery are other MDs, DOs and mid-level providers; including Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) and there are special modifiers. Note: Major surgeries do not qualify for "incident to" services.

Q4. A provider mistakenly sent an incorrect diagnosis for a lab order; the lab submits their claim and it is denied. How do we notify and educate the lab to send in the corrected claim?
A4. Noridian recommends setting an office policy to verify that the correct reimbursable diagnostic code(s) are sent to the lab, before the orders are sent. Providers need to work with their lab on the best process to submit a corrected claim when an error occurs. Another option could include the ordering provider furnishing a copy of the beneficiary's medical record (showing the correct diagnosis) and assist the beneficiary how to file an appeal using their Medicare Summary Notice (MSN).

Q5. Which is the correct administration code for plerixafor (J2562)? Is it 96372 (therapeutic) or 96401 (chemotherapy)?
A5. The correct administration code is CPT 96372 (therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular). If your office received a denial, due to a previous system update, call Customer Service to have the claim reprocessed.

Q6. Are tele radiologists assigned to the technical entity if there are separate technical entities? These radiologists are interpreting and not considered rendering radiologists, as it's another provider for the technical entity.
A6. The billing radiologist needs to be assigned to the technical entity (contracted, leased, etc.) and following those rules for proper billing and reimbursement. This includes licensing in the state where the study is performed. The technical portion would be performed at one location in person. Make sure there is no duplication of the rendering and interpreting billing. FAQs-CR 7631 from 2013 clarifies Place of Service (POS) coding that includes global diagnostic services.

Q7. If a diabetic patient comes in for a diabetic foot exam and paring of a callus was also performed, would the evaluation and management (E/M) for the diabetic foot exam be considered separately identifiable with modifier 25?
A7. Yes. When documentation supports a separately provided service, check the National Correct Coding Initiative (NCCI) website. Providers will see that the E/M code range (99202-99215) states that CPT 11055 (paring or cutting of a benign lesion) has an indicator "1" (modifier 25 may be appropriate); if documentation supports.

Q8. When there are multiple studies performed on the same date of service, should the claims be billed by line or by units with modifier 76 (repeat procedure by physician)?
A8. For multiple studies, it depends on the Medically Unlikely Edits (MUEs). For example, CPT 71045 (chest x-ray, single view) allows up to four per day. However, CPT 71046 (chest x-ray; 2 views) only allows two per day. Appending modifier 76 to the second line of the same code may allow or may deny and prompt an appeal. Providers can find this information under Browse by Topic, titled Modifiers and click into the appropriate modifier.

Q9. CPTs 95718 and 95720 (VEEG; electroencephalogram with video) are denying when performed in a facility setting or place of service (POS) 21. Should these be covered?
A9. Yes. This was a known issue and is now fixed. There were system updates towards the end of February to add place of services 19, 21 and 22. Providers can now reopen their denied claims.

Q10. Can certain hospital Outpatient Department (OPD) services that involve policies such as Blepharoplasty, Botulinum toxin injections, Panniculectomy, Rhinoplasty, and Vein ablation, include POS 11 (office) and 22 (outpatient hospital) for the CMS prior authorization project starting July 1, 2020? Are there any updates?
A10. CMS is requiring several services to be pre-authorized on or after July 1, 2020 in the hospital setting with additional information at this link Prior Authorization for Certain Hospital Outpatient Department (OPD) Services. Only the hospitals and hospital-based Ambulatory Surgical Centers (ASCs) under Part A, with the outpatient prospective payment system (OPPS) and ASC payment systems, will involve the prior authorization project. At this time, the prior authorization will not be required for freestanding ASCs or physician offices submitting claims to Part B Medicare. Therefore, POS 11 will not require prior authorization.

Q11. What constitutes 15 minutes when billing for timed codes such as G0442 or G0444?
A11. These HCPCS state 15 minutes (not up to 15 minutes); therefore, there is no indication that less than time amount is allowed. Please check our website under Browse by Specialty, under Mental Health and under alcohol screening (G0442) and depression screening (G0444). More information can be found in their policies at National Coverage Determination (NCD) 210.8 and NCD 210.9.

Q12. Is the QQ modifier under Appropriate Use Criteria (AUC) still a valid modifier for 2020? If so, is it acceptable to use both a M modifier and the QQ modifier together on same claim line? Example: 78452-26 ME QQ
A12. No. Using a QQ modifier in 2020 will not determine the payment or denial of the claim. In 2021, it will affect payment. It would not be appropriate to use a M modifier and a QQ modifier together as some of the M modifiers contradict a QQ modifier. Use of certain M modifiers require a G code to be added on the claim. Read more at Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Requirements.

Q13. Do echocardiograms (CPTs 93306-93308) fall under the radiology section of the Medicare Learning Network (MLN) Special Edition (SE) 17023 titled "Coding and Billing Date of Service on Professional Claims"?
A13. Yes.

Q14. Is the skin substitute HCPCS Q4117 pricing for 2020 or is the invoice amount still needed?
A14. CMS has not priced Q4117 for 2020. Noridian published an article how to bill skin substitute codes found under Claim Submission titled Skin Substitute Codes. If the provider has specific claim denial examples, after they reflected the invoice price in Item 19 or the electronic equivalent, call Provider Customer Service in your jurisdiction.

Q15. A Licensed Clinical Social Worker (LCSW) provides an assessment service, CPT 90791, in a medical (not psychiatric) hospital. We're told during an audit, that the hospital billing includes social worker services and our claim is not payable to Part B. In what settings are codes billed for psychotherapy and assessments?
A15. Part B covers LCSWs for outpatient mental health services, alcohol and drug use treatments and some screenings in a clinic, physician's office, or therapist's office. An LCSW employed by the hospital would be covered in the hospital setting and paid through Part A. For more Mental Health information, visit Noridian's Browse by Specialty page.

Q16. How frequently does Medicare recertify Skilled Nursing Facilities (SNFs)?
A16. The Code of Federal Regulations (CFR) outlines that a resident must be seen every 30 days, for the first 90 days, and then every 60 days after. The physicians can see more frequently than those parameters; however, they need to support the medical necessity for that visit. If the resident patient has a change in condition that warrants a physician visit, they can bill for a more frequent routine check-up.

Q17. We had a patient in observation status on days one and two and changed to inpatient status on day three. Our claims are being denied because the hospital is billing as an inpatient stay. Do we revert our codes to inpatient?
A17. Yes, due to the overlapping, the claims would need to be changed to mirror the hospital. Common Working File (CWF) will perform a Part A and B crossover report that will indicate to the MACs claims that are subject to the overlapping of A and B those inpatient services will have to be changed to match the Part A services. On the Noridian Part A jurisdiction website, we have resolutions to this issue at JF Overlapping Claim Resolution Tips-Part A.

Q18. Regarding stereotactic radiation therapy, we have a patient with metastatic lung cancer. One week, CPT 77373 or the therapy, is directed towards lung lesions. The next week, five directed towards therapy is to acetabulum (hip) lesions. Can we bill these separately?
A18. No; as this is the same tumor at different sites. CPT 77373 (SBRT treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions) include the possibility of treating multiple sites of disease in one treatment course. Treatment planning is a one-time charge per course of therapy. Billing for multiple treatment plans for a single course of treatment is not allowed; even if two separate plans were created. This is a professional service only and the physician is responsible for all the technical aspects of the treatment delivery planning process.

Q19. Does the 1135 waiver allow payment on the check-in and e-visit codes?
A19. CMS addresses in their current emergency pages at Coronavirus Waivers and Flexibilities.

Q20. Many Health Maintenance Organizations (HMOs) are following Medicare's guidelines. Is telemedicine available for all areas, not only rural areas?
A20. Yes; rural area restrictions have been lifted, at this moment, for all Medicare beneficiaries.

Q21. Regarding telehealth audio/video capability, does it need to be both or one or the other?
A21. Both audio and video are required to meet original telehealth requirements. Read about changes on the CMS website at CMS Regulatory Changes-March 30, 2020.

Q22. With the Telehealth originating site claims, we are receiving denials. Is item 32 where the patient is located during the audio/visual or where the provider is located?
A22. Item 32 needs to be where the patient is located at the time the services are being rendered. If the patient is not in an eligible originating site, then the other services would not be valid. Bill the originating place of service with HCPCS code Q3014 only.

Q23. If providers want to provide Telehealth and aren't working from their homes 100%, does our practice still need to add the provider's address to the enrollment application?
A23. Providers are not required to report their home address if providing telehealth services from their home. Confirm with the Noridian Enrollment department by calling the established hotline number 866-575-4067. This is also intended for providers or organizations that are in emergency situations that need to be enrolled quickly due to the Coronavirus. CMS has Telehealth information at CMS Telemedicine Healthcare Provider Fact Sheet.


            Last Updated Fri, 17 Apr 2020 16:59:29 +0000