The following questions and answers (Q&As) are cumulative from the general 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 this directly with the provider. This session included pre-submitted questions and verbal questions posed during the event.

Q1. How can CPTs 15277 (skin substitute graft application; first 100 sq. cm) and 15278 that were rejected for the age of the patient be paid without appeal rights?
A1. In August 2021, Medicare system edits were updated to remove age limitations and Noridian reprocessed claims that had denied incorrectly. If a provider finds they have outstanding claims that were rejected for this reason, they may resubmit as a new claim.

Q2. This question applies to our physician-owned lab and radiology that perform the readings and are the same entity performing the E/M. When an x-ray is performed bilaterally (two radiology reports and separate imaging), would this count as one or two tests in the Medical Decision-Making (MDM) of an Evaluation and Management (E/M) visit?
A2. Only if the provider, group, or clinic is not billing for the x-ray or other radiology as well. The MDM may count as two tests for the Evaluation and Management (E/M) billing; but only if those x-ray tests are not billed separately for the interpretation and report of the resulting image. It's a deviation from historical counting of "points". Providers cannot count in the medical decision-making (MDM) data evaluation because your clinic is already reimbursed for the ordered test.

A unique test is defined by the CPT code set. When multiple results of the same unique test (e.g., serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count. More information can be found at Noridian posted in the ACT March 2021 answers to E/M questions under Education and Outreach.

Q3. When a non-interventional cardiologist performs coronary angiography (CPT 93458) and a second interventional cardiologist performs intravascular ultrasound (IVU) with CPT 92978, why are they denied for not having a "parent code"?
A3. CPT 92978 is an add on code and should pay with the use of the 93454-93461, when billed by the same provider for the same patient on the same date of service. Always check the CMS National Correct Coding Initiative (NCCI) Add-on Code Edits webpage.

Q4. Will HCPCS C1734 (orthopedic implantable device) be reimbursed with the J7 pass-through status code that is "Contractor Priced"? Are there pricing limitations and is there a policy?
A4. HCPCS C1734 always requires an invoice, and this information can be found on Noridian's Claims Submission page on avoiding denials. It can be billed with CPTs 27870, 28715, 28725. Currently, there is no Local Coverage Determination (LCD), or National Coverage Determination (NCD) policy attached to this code.

Q5. Under E/M guidelines, what is the difference between major and minor surgery if not the global days?
A5. The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, like the use of the term "risk." These terms are not defined by a surgical package classification.

Q6. How should we document prolonged face-to-face (F2F) care services (99356-99357) if performing CPT 99223 (E/M inpatient) with greater than 50% of time spent on the patient face-to-face, and we document total time spent?

Q1. Can prolonged care (99356-99357) be billed without start/stop times?
Q2. Can prolonged care (99356-99357) be billed when physician work is non-face-to-face activities?
Q3. Do the CPT time rules apply when the mid-point is passed?

A6. The three answers include:

A1. Start and stop times must be documented in the medical record along with the date of service.
A2. Physicians may count only the duration of direct face-to-face contact between the physician and the patient (whether the service was continuous or not).
A3. Threshold mid-point examples are provided on the CMS Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.15.1.G under Prolonged Services.

Codes 99356-99357 are used to report the total duration of time spent by a physician or other qualified health care professional at the bedside and on the patient's floor or unit in the hospital or nursing facility on a given date providing prolonged service to a patient. The use of the time-based add-on codes requires that the primary evaluation and management service have a typical or specified time published in the CPT codebook. Code 99355 or 99357 is used to report each additional 30 minutes beyond the first hour, depending on the place of service. Either code may also be used to report the final 15-30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately. More information is found on the American Medical Association (AMA) website in the CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes document.

"Documentation is required in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services billed. The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. The start and end times of the visit shall be documented in the medical record along with the date of service."

Q7. Is a provider able to bill prolonged non-F2F CPT codes 99358/99359 on a date of service that is different from the related office E/M visit (e.g., 99202-99205)?
A7. Yes. 2021 CPT guidance states codes 99358, 99359 can be performed on the same date or another date as E/Ms 99202-99215. This can be found in the CMS IOM Publication 100-04, Chapter 12, Section 30.6.15.2 titled "Prolonged Services Without Direct Face-to-Face Patient Contact".

Noridian expects these non-face-to-face codes will rarely be billed. Provider documentation must include start and stop times that show a minimum of 31 minutes spent on time directly related to an E/M visit. If the time occurred on a different date than the visit, you must reference the date of the non-face-to-face service and include a brief description of how that time was spent (e.g., nature or topic of what was reviewed or discussed).

Q8. Is there any difference between CMS and the American Medical Association (AMA) 2021 E/M codes (99202-99215), when counting time for prolonged service CPT 99417 or HCPCS G2212?
A8. Yes. The difference between the prolonged code HCPCS G2212 (recognized by CMS) versus CPT 99417 (recognized by the AMA) is the start times. There's a difference between 99417 starting after the 99205 or 99215. G2212 starts after 89 minutes for 99205 and 69 minutes for 99215.

Q9. Can Noridian please provide an acceptable statement example to document for supervision of moderate sedation during a procedure?
A9. Medicare can provide guidance on the requirements of the procedure; however, cannot indicate acceptable statements to include in the documentation. The physician supervising a specially trained sedation nurse would need to be indicated. The trained observer monitoring the patient would need to be indicated along with their credentials.

Q10. During the Public Health Emergency (PHE), we have an increase in electronic signatures returned on prescription request forms. Will CMS contractors accept a "digital signature" if no e-signature tag line is visible?
A10. Providers would need their "electronically signed by" indicated in their medical documentation. The PHE did not provide any waivers to signature requirements. Review the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 for signature guidelines or refer to the Complying with Medicare Signature Requirements fact sheet.

Q11. For time associated with screening services, alcohol misuse (G0442) and cardiovascular intensive behavior therapy (G0446), is the service met if "up to 15 minutes" like it is with the depression screening (G0444)? If the doctor doesn't document the time, can it still be billed because it doesn't say "up to 15 minutes". How do we receive payment? How about with the 30 minutes for Advance Care Planning (ACP) or CPT 99497?
A11. Noridian recognizes this is a known challenge and have reached out to the CMS Medicare Learning Network (MLN) committee in November 2021 to look at the screening and preventive timed services. When we receive clarification, we will publish on our website. For the G0444, Noridian follows the definition of "up to 15 minutes"; where Medicare covers when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. The language can be found in the CMS IOM Publication, 100-04, Chapter 18, Section 190. For the ACP, Medicare follows the CPT definition beyond the mid-point. In this case, at least 16 minutes would need to be documented.

Q12. In the Federally Qualified Health Center (FQHC) setting, if a medical E/M visit is furnished for chronic problems such as hypertension (HTN) and Diabetes, and an Annual Wellness Visit (AWV) is also completed, should both be billed? The CMS IOM Publication 100-02, Chapter 13 says "if the AWV is furnished on the same day as another medical visit, it is not a separately billable visit."
A12. The FQHC Prospective Payment System (PPS) will pay the lesser charge of what Medicare will pay. In the CMS IOM Publication 100-04, Chapter 9, Section 60.3, there are some payment examples for FQHC Prospective Payment System (PPS) claims.

Q13. "BioFire Respiratory Pathogen (RP) 2" lab panel CPT code 0100U is discontinued effective April 1, 2021?. Will Medicare have a CPT to replace the Proprietary Lab Analysis (PLA) code?
A13. The Local Coverage Article (LCA), Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels (Revision) R13, states 0098U, 0099U and 0100U were deleted and the code description was revised for 0202U (22 targets) and 0225U (21 targets).

Q14. Under an undiagnosed new problem with uncertain prognosis, we want to clarify that it MUST be a condition likely to result in a high risk of morbidity without treatment.
A14. This all depends on the situation, documentation, and medical necessity to perform an independent review, separate from the lab or radiology as CMS is following the definition as indicated by the American Medical Association (AMA). Some of the bullets under the number of problems addressed indicate "one or more". This means that additional problems in that bullet would still count for one bullet. Choose your level based on the problem(s) addressed and the highest level or problem(s) indicated. Look to the other two elements, data, and risk, to determine if a higher level of service is appropriate.

Q15. Can Noridian clarify if the Certified Registered Nurse Anesthetist (CRNA) can charge a peripheral nerve block separately to control postop pain for a surgery with general anesthesia with a modifier? What documentation is needed and if provided preoperatively, can it be charged?
A15. A nerve block provided any time during the anesthesia period of care for post-operative pain management is only separately payable when the request is documented by the surgeon. This would not be the anesthesia mode, nor can the adequacy of the primary anesthesia technique be affected by the peripheral block. As far as who can place the block, that is determined by the state. The American Society of Anesthesiologists (ASA) has posted a Statement on Reporting Postoperative Pain Procedures in Conjunction with Anesthesia on their website that follows CMS resources.

Q16. If one chooses to do intra-articular (IA) steroid injections, does one have to provide two diagnostic injections with local anesthetic first and document at least 80 percent relief; then bring the patient back for the steroid injection at the third visit? Why do patients have to wait two weeks between diagnostic medial branch nerve block #1 and #2 when the anesthetic only lasts one-two hours?
A16. If the intra-articular steroid injections are performed for therapeutic purposes, the LCD requirements need to be met, which includes two medically reasonable and necessary diagnostic facet joint procedures with each one providing at least 80% relief of primary pain (with the duration of relief being consistent with the agent used). The therapeutic IA injection would be a third visit. The Limitations section of the LCD notes, "Facet joint intraarticular injections and medial branch blocks may involve the use of anesthetic, corticosteroids, anti-inflammatories and/or contrast agents, and does not include injections of biologicals or other substances not FDA designated for this use." There is evidentiary analysis in identifying facet syndrome with a two-week wait period from the initial injection. Please refer to the Summary Evidence section of the LCD for more detailed information.

Q17. If a patient receives the Chronic Lower Back Pain (cLBP) benefit for 12 Acupuncture visits in 100 or 120 days; could they still benefit for the additional eight visits or must all visits be completed within the 90 days?
A17. Yes. Up to 12 visits in 90 days are covered for Medicare beneficiaries meeting the NCD criteria. An additional eight sessions will be covered for those patients demonstrating an improvement. NCD 30.3.3 titled Acupuncture for Chronic Lower Back Pain (cLBP) says up to 12 visits in 90 days is covered. If the patient returns after 90 days; they can start the cycle again. The NCD is very specific for additional eight sessions of no more than 20 per year. Treatment must be discontinued if the patient is not improving or is regressing. For more information, read the CMS IOM Publication 100-3, Chapter 1, Part 1, section 30.3.3. and change request (CR) 11755 guidelines to clearly document that the patient is responding as a factor for additional visits.

Q18a. Regarding Moderate Sedation PRE-service work listed in the CPT, does each component need to be documented?
A18a. When billing for moderate sedation, all the preservice work listed in the CPT book would need to be included in the documentation. Sub-bullets for focused examination would be necessary for each system. The Mallampati score assessment would be allowed for the mouth, jaw, oropharynx, neck, and airway.

Q18b. Regarding Moderate Sedation INTRA-service work, how should the monitoring provider and their time be documented?
A18b. The qualified independent trained observer would be documented in the medical record along with their time involved in patient monitoring.

Q18c. Regarding Moderate Sedation POST-service work; when communicating with the family/caregiver regarding sedation service, does this need to be specific to the sedation service? Can a check list be reviewed? What if the patient instructs to not share information?
A18c. The documentation would need to support discussion with the family/caregiver specific to the sedation service as listed in the CPT requirements. "Do Not Share" indicated would need to be questioned. Who is transporting this patient? Will they have someone to monitor once they have been discharged? The sedation discussion needs to include someone other than the patient in case there are post-symptoms related to the sedation. Noridian can't state if a checklist would be appropriate and states that documentation would need to support the sedation discussion.

Q19. Local Coverage Article (LCA) A58533, under "group One" instruction, states the self-administration formulation of Cimzia is not a benefit and the formulation with the GY modifier is a statutorily excluded service. We have nurses administering pre-filled syringes in the office. Will we have to use the vials to receive reimbursement for Cimzia (J0717) for treatment of plaque psoriasis, Crohn's Disease, etc.?
A19. At the time of this response, regardless of formulation (vials or pre-filled syringes), Cimzia (J0717) is not on Noridian's Self-Administered drug (SAD) list. Should any changes to the SAD list occur, Noridian will post the website update with time for transitioning. Since there is current confusion as to whether the drug in question may be self-administered or not, Noridian will work to address.

Q20. When reporting E/M CPT 99211, is a medically appropriate history and/or physical exam required? If so, would collecting the vital signs be considered an exam element?
A20. No. The American Medical Association (AMA) does not indicate history and/or exam for 99211. Time is reported and documentation would be separate from any reported procedure.

Q21. Our clearinghouse is resubmitting a second time causing a duplicate denial. The first claim is getting partially paid. Is there a way on the Noridian website to have multiple claims?
A21. Noridian will forward the recommendation for the Noridian Medicare Portal (NMP) team to allow more than one claim to be adjusted with the Self-Service Reopening. However, the editing is in place to ensure the single claim passes required logic to be received as an adjusted claim. Noridian is processing claims timely and electronic data interchange (EDI) has identified they have received back-to-back or day-after-day submission. Providers and clearinghouses need to work with EDI to submit clean claims and wait at least 30 days. Providers are encouraged to work with our EDI directly. Providers need to verify the status of claims before rebilling.

Q22. LCA A56515 for MOHs surgery does not show a covered diagnosis for "carcinoma of the skin trunk". Is it appropriate to bill "other site"?
A22. No. Please email MPreconsideration@noridian.com and provide the details to have this diagnosis considered to be added to the MOHs Local Coverage Article.

Q23. When performing Image-Guided Radiation Therapy (IGRT), does the physician billing the 77014 (CT guidance for radiation therapy field replacement) need to be present at the time images are obtained? Can they be reviewed remotely prior to the next treatment?
A23. Only the presenting physician, supervising the service, may charge for the guidance code(s), whether approved today or tomorrow. The image must be approved prior to the next treatment and the physician would bill the global code and fee when the procedure occurred.

Q24. Regarding the updates for bilateral Radiofrequency Ablations or RFAs policy; if a patient is scheduled on a single day (bilateral L4-5, L5-S1 RFA), does that count as one session? Would we bill CPT 64635 with modifier 50 or 64636-50 and count as one session?
A24. Yes. If L4-5 and L5-S1 bilateral RFAs are completed on the same date of service, 64635-50 and 64636-50 would be billed as two bilateral facet joints, targeted on the same encounter date, which is considered as one session. In total, the beneficiary would have two sessions completed towards the frequency limitations of the policy which notes; "For each covered spinal region, no more than two radiofrequency sessions will be reimbursed per rolling 12 months." Note: Modifier 50 is not allowed in the Ambulatory Surgical Center (ASC). When bilateral procedures are performed in the ASC, append the RT and LT modifiers.

Q25. With the updates for the RFA policy, if a patient needs three to four-level procedure bilaterally, would that be covered?
A25. The third and fourth level would be denied on the initial determination. Three or four unilateral or bilateral levels may be considered medically necessary with sufficient documentation to substantiate the medical necessity on an appeal.