Article Detail - JF Part B

Q1. When billing for Ambulatory Electroencephalogram or EEG with video, should CPT 95951 or CPT 95953 be billed?
A1. CPT 95953 is unattended: "…leads are placed and the patient is sent home…". CPTs 95951 and 95956 are both attended studies and used for recordings in which interpretations can be made throughout the recording time, with interventions to alter or end the recording or to alter the patient care during the recordings as needed. See the CMS National Coverage Determination (NCD) Ambulatory EEG Monitoring (160.22).

Q2. For Factor Eight (VIII) drugs narrative, should a provider use the date of delivery or the actual date of service (DOS)?
A2. Providers should use the actual date the drug was administered if delivered within a facility or "incident to" a physician's service. If this is billed by a pharmacy, in order to replenish the patient's home supply, then use the date of delivery.

Q3. How is non-myeloid defined? Does this include leukemia and all types of lymphoma? If a patient has a non-myeloid primary, such as breast or prostate cancer, but also has metastasis to the bone, do those diagnoses meet the policy criteria?
A3. Used in this context, Myeloid refers to those malignancies derived from myeloblasts. These are different from the progenitor cells for lymphacytes. "Non-myeloid" malignancies are defined as types of leukemia.

Q4. Is a patient required to see an MD before he/she sees a mid-level provider (MLP) such as an Advanced Practice Nurse (APN)?
A4. To see the patient first, the MLP must be certified, have their own Medicare Provider Transaction Access Number (PTAN) and would not bill as "incident to."

Q5. Can a consulting psychiatrist and/or a psychologist bill HCPCS G0502, G0503 and G0504 for Psychiatric Collaborative Care Management (CoCM) services or is this for the patient's Primary Care Provider (PCP) only?
A5. Psychiatric CoCM services may be billed on a monthly basis by the primary care provider only who employs a behavioral health care manager and has a separate financial arrangement to reimburse that psychiatrist.

Q6. Since CMS is not using the new modifier 95, what modifier is used for telemedicine?
A6. Continue appending the current modifier GT (via interactive audio & video telecommunications); or in Alaska or Hawaii, use GQ for the synchronous telecommunication system.

Q7. If an Interventional Cardiologist performs a procedure with a 90-day global period, can a cardiologist from the same group perform the postoperative visits? Are the postop visits by the other Cardiologist reported as global visits (CPT 99024) or should the postop visits be reported as evaluation and management (E/M) visits because the cardiologist is a different specialty?
A7. If there isn't a written statement to transfer the postop care, the surgeon will receive the global payment. Modifiers 54 or 55 are only used when a transfer of care is established.
If the cardiologist is seeing the patient for other medically necessary services, then an E/M could be appropriate as CPT 99024 is not yet recognized.

Q8. Is a clinical social worker (CSW) required to be credentialed with Medicare in order to bill the Advance Care Planning (ACP) 99497 and 99498 "incident to" the physician?
A8. A CSW cannot bill for the monthly ACP complex codes; however, the CSW's time and services may contribute toward the monthly ACP physician billing. Per the 2016 Physician Fee Schedule (PFS) final rule (80 Fed. Reg. 70956), the services described by CPT codes 99497 and 99498 are appropriately provided by physicians or using a team-based approach provided by physicians, nonphysician practitioners (NPPs) and other staff under the order and medical management of the beneficiary's treating physician.

Q9. Will ICD-10 diagnoses C43.21 and C43.22 be added to the Mohs Local Coverage Determination (LCD)?
A9. The Mohs Micrographic Surgery LCD was updated January 24, 2017 and can be found on the Noridian Active LCDs webpage under Policies. These two diagnoses C43.21 (malignant melanoma of right ear and external auricular canal) and C43.22 (left ear) were added.

Q10. Does reviewing notes in a shared electronic health record (EHR) provide credit towards the medical decision making data component of an E/M service? Are the records that are reviewed need to be requested from an outside (the EHR) source? Is there a general acceptance that any note that is reviewed would be considered "old records" (review and summarize old records)?
A10. Only if pertinent to the problem being evaluated.

Q11. Why is a service that is denied by Noridian have reimbursement information on the Medicare Physician Fee Schedule? E.g., CPT 10040 supports payments for facility and non-facility.
A11. This is acne surgery and generally considered cosmetic. This may be appealed and confirm in the clinical records that the usual care has not worked.

Q12. When Tetanus, Diphtheria and Acellular Pertussis (Tdap) is not covered, can a provider bill the administration to the beneficiary or does the provider have to write it off? 
A12. Whenever an immunization or vaccine is non-covered (e.g., Tdap booster shot), the administration will also be denied. Providers should append modifier GY to the CPT code. The beneficiary may check with their Medicare Part D plan for possible coverage, but they are still financially responsible. Noridian does cover Tdap for wounds and injuries and there is more information published on the Noridian website titled "Tetanus and Diphtheria Vaccinations Billing Guidelines."

Q13. Can a pharmacist bill "incident to" for a service that is higher than a CPT 99211?
A13. No. If the physician does not see the patient on that particular visit, then no level higher than a 99211 may be billed. The higher levels include physician work (face to face time with the physician); however, physicians may bill for pharmacists working "incident to" if they meet the "incident to" requirements and operating within their scope of practice and state laws.

Q14. A patient is in observation and the hospitalist charges for an initial CPT 99218. On the same day a neurologist from the same group (both employed by the hospital) sees the patient as well. Does the neurologist bill a subsequent observation or an E/M code?
A14. He/she will bill an E/M visit.

Q15. How can a provider submit a claim when Provider A bills the primary code and Provider B performs the add-on codes on a separate claim?
A15. Two (2) separate providers would not bill separately, as the add-on code has to be billed on the same claim as the primary code and by the same physician. The two (2) physicians could agree on a financial arrangement between them, but only one physician can bill.

Q16. Is place of service (POS) 02 for Telehealth originating site or distant site? If a telehealth patient presents from a non-rural location or an ineligible site of service (home or car), is the documentation required to indicate the originating site to support the GY modifier?
A16. The new POS 02 is for the distant site, where the practitioner is providing the Telehealth via his/her office. If the patient's not located in an approved site of service and the service is statutorily excluded, a provider may submit a claim with a GY modifier or not bill at all.

Q17. Can a nurse practitioner (NP) bill for an in-person CPT 93289 (interrogation device evaluation with analysis, review and report by a physician or other qualified health care professional that includes connection, recording and disconnection per patient encounter; single, dual or multiple lead transvenous implantable defibrillator system, including analysis of heart rhythm)?
A17. Yes. If their state scope of license allows. For CPT 93289, the entity must have a qualified healthcare professional (including NPs) available 24 hours a day to answer telephone inquiries. Se the NCD Implantable Automatic Defibrillators (20.4) and the CPT manual which contain a plethora of information. Other qualified healthcare professionals include registered nurses, physician assistants, nurse practitioners, certified registered nurse anesthetists, and physical, speech, occupational, and massage therapists. All have demonstrated skill and expertise in their field of study to complete the education and regulatory requirements, to obtain licensure, and to remain in good standing with the respective licensing boards.

Q18. Does moderate sedation HCPCS G0500 reporting require at least the full 15 minutes or at least 8-10 minutes (over half of the 15-minute requirement) similar to CPTs 99151 or 99152?
A18. The new CMS HCPCS G0500 time is defined as "Moderate sedation…; initial 15 minutes." Even though CPT states: 10-22 minutes for 9915x moderate sedation series, since the HCPCS description says initial 15 minutes of intra-service time, then Medicare would expect at least the full 15 minutes of service.

Q19. Is there a new administration code in place of CPT 96377 for the chemotherapy injection not recognized by Medicare?
A19. CPT 96372 (subcutaneous administration) is the appropriate CMS code that Medicare recognizes. This includes the chemotherapy kit for patients to take home and self-inject the next day and relieves patients from returning to the Chemotherapy center for that injection. This would be billed with the vaccine HCPCS J2505 (Pegfilgrastim or Neulasta).

Q20. Sometimes our physicians are at the hospital and consult with other physicians about the other physician's patients. Can a provider bill if the physician does not see the patient face to face?
A20. No. In this case, Medicare call this "curbstone or coffee consultations" and billing the patient without patient involvement and agreeing to this physician-patient relationship is not a Medicare benefit.

Q21. Is the only instance where Medicare will pay for patients receiving parenteral iron administration for iron deficiency anemia with chronic kidney disease? Can the patient be covered for iron deficiency anemia as they can't tolerate oral medications?
A21. When physicians are looking at the patient (before they go parenteral), the vast majority will tolerate oral iron and there has to be a reasonable trial and then definitely shown. Now, there are some circumstances such as someone with a "short gut syndrome" and some other issues like that and as long as that's clearly documented in the chart, then Medicare would cover. There has to be a very distinct, clear reason in the chart why the patient was given parenteral over oral without a trial of oral first, because most patients do well with oral. The stomach's really good at absorbing iron.

Q22. If the physician is performing an annual wellness visit (AWV), is it acceptable for them to bill a HCPCS G0444 for depression screening as well? Is there a certain template? Can a provider bill an E/M code if the physician sees the patient's family members for counseling?
A22. When billing the AWV, there is already a component included for depression screening. HCPCS G0444 says that there are various tools that could assess the screening. It is up to the provider's facility as what to use for this screening but Medicare recommends using one of the national comprehensive screening tools put out by different organizations. The family members may substitute for the patient when the patient is not able to provide the information. Otherwise, feedback or advisement must be made to the patient. It is part of post service work (over and above) but not covered for additional billing. Family members can be seen as long as the patient is with them.