ACT Questions and Answers - May 18, 2017

Providers Note: Answers 2, 3 and 4 have been updated to include clarification and modified replies from those provided during the ACT call.

Q1. Is a physician required to restate "moderate sedation" details in the procedure note or refer to scanned sedation forms or nursing notes? Is a physician required to include the intra-sedation start and stop times or will total time suffice and document the independently trained observer's name in the procedure note?
A1. Noridian does not prescribe to a particular form of documentation for this service. The medical records should document the service that was performed, name and credentials of the persons providing the service and the total times involved. There needs to be a clear documentation of the conscious sedation in the record, either as a separate note or as an integral part of the procedural note. Here are bullet points to address:

  1. Pre-procedure evaluation
  2. Conscious sedation start time, medication dose, route of administration, name and credentials of the trained observer
  3. Intraprocedural monitoring (e.g., chart for anesthesia uses)
  4. Any additional dosing required and why (e.g., patient was restless)
  5. Number three could be extended until discharge, if desired
  6. Post procedural evaluation prior to discharge
  7. Any additional documentation required by the respective state regulatory entities

Q2. Should modifiers 24 and 52 be appended for a post-op complication during a global period? Are all complications not requiring a return to the operating room (OR) included in the global surgical package or could some unusual complications be billed with an Evaluation and Management (E/M) and modifier 24?
A2. It depends on the situation.

  • View the Modifier 24 webpage. Modifier 24 is for an "unrelated evaluation and management (E/M) service by the same physician or other qualified healthcare professional during a post op period."
  • View the Modifier 52 webpage as it states "partially reduced or eliminated service or procedure at the discretion of the provider." Depending on the severity of the complication and the global period assigned to the surgical procedure (10 or 90-day), if a return to the operating room is necessary, then a modifier 78 is more appropriate. An office visit for minor services like change of bandages is included in the global package any not billable.

Q3. When a new patient is seen, a provider typically bills an E/M CPT 99201-99205; however, if the documentation only contains two (2) of the three (3) required components of the history of present illness (HPI) and medical decision-making (MDM), is an established E/M CPT (99211-99215) or an unlisted E/M CPT (99499) correct?
A3. To bill for a new patient office visit, three (3) of the key components must be met. If only two of the three components are met, providers must down code it to a subsequent visit code, if the medical records appropriately demonstrate that the work and medical necessity requirements are met for reporting a subsequent visit code. CPT 99499 should only be used in limited cases where there is no other specific E/M code payable by Medicare that describes the service provided. Reporting CPT 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Do not send documentation with the claim. Noridian will send an Additional Documentation Request (ADR) requesting documentation for the unlisted E/M service after the claim has been received.

Q4. In an inpatient hospital setting, when an E/M is furnished and there is no other specific E/M CPT reimbursable by Medicare which describes the service, is it appropriate to report the unlisted CPT 99499 for consultation services (CPTs 99251-99252)?
A4. Medicare has not covered consultation codes since 2010 as stated in Medicare Learning Network (MLN) Matters Special Edition (SE)1010. Providers are advised to bill with the appropriate E/M CPT that represents where the visit occurs and identifies the complexity of the visit performed. Contractors expect reporting CPT 99499 under these circumstances to be unusual. Typically, an E/M service must reflect at least the minimum requirements of the lowest level of code in a code family to be paid. Providers are instructed to select the highest-level service within a category or subcategory of E/M codes for which all criteria are met. If all the E/M criteria is not met, then a lower level subsequent code must be selected. When billing CPT 99499, a concise description of the type of service is required in Item 19 on the CMS-1500 claim form or the electronic equivalent. Examples of descriptions include: "office/other outpatient visit," "hospital admission," etc. Do not send documentation with the claim. After a claim is received, Noridian will send an ADR for documentation for the unlisted E/M service. See CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 30.6.1 and 30.6.8.

Q5. Does CMS require 60 plus + minutes as required time for billing CPT 99358 (non face-to-face prolonged E/M) or does it follow CPT guidelines that state 30-60 minutes also supports this charge? What about the add on CPT 99359 (30 plus + minutes) or does 15 minutes also support this charge?
A5. The first CPT 99358 is described as prolonged E/M services before and/or after direct patient care, first hour. The prolonged service must be in relations to other physician services like an E/M on another day. Providers must keep track of the total time of this non-face to face time spent. It does not have to be on the day of the E/M visit, nor does it have to be continuous, but if the total time is less than 30 minutes, it is not billable. CPT 99359 is for each additional 30 minutes beyond the first hour on the same given day. If it is less than 15 minutes, then it is not separately reportable and just the first hour is billable. Medicare states 60 minutes must lapse prior to billing. CMS has posted a file on the PFS Federal Regulation Notices webpage that notes the times assumed to be typical, for purposes of Physician Fee Schedule (PFS) rate-setting. "While these typical times are not required to bill the displayed codes, CMS would expect that only time spent in excess of these times would be reported under CPT codes 99358 and 99359."

Q6. When the documentation does not meet the lowest requirement to capture an inpatient admit (CPT 99221) and a subsequent CPT 99231-99232 is chosen, are providers required to append the modifier AI to the subsequent E/M CPT?
A6. For an initial hospital admit visit, three of the three key components must be met. If only two of the three components are met, then providers can down code to a subsequent visit code if the medical records appropriately demonstrate that the work and medical necessity requirements are met for reporting a subsequent hospital care code even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay. The modifier AI is appended to the subsequent visit code if the provider is the attending and principle care physician.

Q7. What is the appropriate way to bill CPT 96118 (neuropsych testing by physician with test results interpretation and report preparation) if an outside physician (at a separate facility) provides it? Should the provider who starts the computerized version of the test bill CPT 96120 (neuropsych testing by computer with interpretation and report)?
A7. Both physicians must communicate with each other as to who will bill this test if this is the same test and provided two (2) different ways. Medicare will not cover both codes for the same patient on the same date of service (DOS).

Q8. When Medicare is secondary and the primary insurance requires that a provider bills a bilateral CPT with modifier 50, are providers required to change the billing for Medicare to show right (RT) and left (LT)?
A8. It depends on the code(s) billed. Check the 2017 Medicare Physician Fee Schedule (MPFS) Indicator List under the B (bilateral) column and match to the fee schedule descriptor list to see if a modifier is appropriate. Providers will not append modifier 50 to a "bilateral description" code or midline organ procedures (i.e., bladder, uterus, esophagus or nasal septum) or different areas such as the left knee and right shoulder. Submit with appropriate modifier (50 or RT/LT) as required for Medicare billing.

Q9. If an ophthalmology department hires a certified "orthoptist," can they perform both CPT 92060 (sensorimotor exam w/multiple measurements of ocular deviation; interpretation and report) and CPT 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation)? Is it appropriate for the orthoptist to work "incident to" an ophthalmologist?
A9. Yes. If the "orthoptist" is operating within their scope of practice and following state laws and "incident to" rules. The MPFS allows these codes either as global, technical or professional for billing.

Q10. Can a Licensed Clinical Social Worker (LCSW) bill "Incident To" for Advanced Care Planning (ACP) services under a physician outside of the mental health specialty? Please explain "team based approach" for the LCSW and ACP.
A10. No. An LCSW may only bill CPT 99497 (advance care planning) for their scope of practice or the mental health specialty. See the CMS ACP FAQs for more information. Under ACP, an advance directive is a document appointing an agent and/or recording the wishes of a patient, pertaining to his/her medical treatment at a future time should s/he lack decisional capacity at that time. Team approach operates under the order and management of the treating physician.

Q11. Is the guidance still valid that was provided in the October 23, 2013, Noridian article titled "Date of Service on Professional Component of Diagnostic Testing Procedures?"
A11. At this time, no further instruction has been released from CMS. No updates have been made to the CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 26. Billing requirements are at the Medicare Administrative Contractor (MAC) discretion. The technical component is billed on the date the patient had the test performed. The professional component is billed on the date the physician provided the interpretation and report of the radiology service. If these are provided on different dates, bill with those different dates and append, where applicable, modifier TC and modifier 26.

Note: In 2009, CMS rescinded Change Request (CR) 6375, which clarified place of service (POS) and date of service (DOS), instructing providers to report the DOS as the date of the interpretation. In 2013, CMS released CR 7631, which clarified the POS professional component (PC) and technical component (TC); however, was silent on the DOS. Under CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 20, it refers to the date the beneficiary received the item or service, regardless when ordered or paid. When billing globally for a radiology procedure, Noridian accepts the date of the test (TC) or the date of the interpretation (PC) as the DOS. If requested, medical documentation must support the services billed.

Q12. Can an acupuncturist enroll as a billing provider under their own National Provider Identifier (NPI) or bill "incident to" to perform massages?
A12. Acupuncturists are not allowed to enroll or bill "incident to" as their state law and scope of license does not cover Medicare. Acupuncture and massage therapy are not Medicare benefits.

Q13. A patient normally sees one Nurse Practitioner (NP) within a provider's practice, however, within three (3) years, he/she sees another NP within the same family practice, who is collaborating with a physician of a different specialty (orthopedic). Is it appropriate for the second NP to report a new patient visit?
A13. The second NP will bill "established" as NPs are all under the same specialty 50; they are not separated like physician specialties. Medicare interprets the phrase "new patient" to mean a patient who has not received any professional services such as E/M visits or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. See CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.7.

Q14. A patient is diagnosed with cancer. Chemotherapy will begin three days following the first appointment. Is it acceptable for a provider to bill for a second appointment to Medicare for chemotherapy education (no other chief complaint) provided by a Registered Nurse (RN), Physician Assistant (PA) or NP? Is there a difference between oral medication and IV medication?
A14. No. There is no separate code allowed to bill for "chemotherapy education" by any provider. The education can be provided at the initial appointment or wait until the day that chemotherapy begins. Most codes have relative value units (RVUs) for counseling and education built into the chemotherapy administration CPT code. For more information, view the Noridian Oncology and Hematology webpage and review the CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 17.

Q15. The Electronic Medical Record (EMR) contain several fields where an ordering provider's name may be entered: Authorizing Provider, Signing Provider, Responsible Provider and Electronically Signed By field. Which signature field determines who the referring/ordering physician is?
A15. All four fields mentioned should contain the same physician's name. In a situation where the signature of the person printing or faxing the order is displayed in the electronically signed field, physicians must have a system and software product which are protected against modifications and should apply administrative procedures which are adequate and correspond to recognized standards and laws. This provider bears the responsibility for the authenticity of the information.

Q16. A provider appealed yttrium (ph) or Y90 TheraSpheres and Sir-Spheres claims that had denied due to "clinical trial" requirements. To receive the Y90, does Noridian require a patient to be in a clinical trial? Is this a recent National Coverage Determination (NCD) revision?
A16. There are two products which are the particulate and the radio-labeled microspheres. Both are approved through the FDA for very limited use for hepatocellular cancer and metastatic colon cancer. They are not approved for any other use beyond that and other indications are not sufficiently justified in the literature. The problem with these products are adverse effects from radiation to the liver, including fatal adverse effects. Noridian believes that before these are allowed, there should be an adequate clinical trial to prove they are both safe and effective. Providers may appeal and include scientific literature from the peer review journals to support the rare use.

Q17. With provider-based E/M codes, isn't the new vs. established patient based on specialty?
A17. The new vs. established E/M difference is whether a "patient was seen in the last three years by the same/different specialties or group practice of same specialty" or not as recognized by Medicare. If both providers are different specialties, but are enrolled in Medicare under the same specialty, a denial may occur.

Q18. In a provider's outpatient infusion center, CPT 96365 is billed when a patient comes in the morning, leaves and comes back in the afternoon. Is it appropriate to append modifier 59 to the second code?
A18. No. Modifier 59 is not used for the same code billed twice on the same day as it does not meet the National Correct Coding Initiative (NCCI) edits or rules. Look at Modifier 76 as it may be more appropriate.

Q19. Will Noridian accept the below phrases if written by a billing provider for the professional fee portion of an EKG? The *** (#3 and #4) will be in an EMR program which allows a physician to customize their documentation.

  1. Normal EKG: "I personally reviewed the tracing and agree with what is indicated in tracing."
  2. Abnormal EKG within normal limits: "I personally reviewed the tracing and agree with what is indicated in tracing. Although the results are abnormal, this is within normal limits for this patient."
  3. Abnormal EKG: "I personally reviewed the tracing and agree with what is indicated in tracing. The findings are consistent with ***."
  4. Comparative EKG - Abnormal: "I personally reviewed the tracing and agree with what is indicated in tracing. Compared to the prior EKG. The findings are consistent with ***."
  5. Comparative EKG - Normal: "I personally reviewed the tracing and agree with what is indicated in tracing. Compared to the prior EKG. The findings are within normal limits."

A19. If a provider is billing for the interpretation, none of the options listed are correct. The document should specifically state what the provider sees on the EKG and report. If a provider is billing for the interpretation, he/she should report what is found in the tracing, instead of agreeing to the review of tracing. Providers must document in the progress notes what is found.

Q20. A pathology professional piece (e.g., lesion removal CPT 88305-26) is performed at the provider-based outpatient hospital office location (place of service ((POS) 22). What POS should a lab bill? Should it be reflected that the work is performed at the hospital (CMS-1500 / Item 32 address)? The specimen is sent to the provider's office to prep with a technical and professional piece.
A20. Yes, to both questions. The Pathology POS is not where the patient was located when the specimen sample was collected; but where the pathologists are performing the service. The hospital will bill the technical (CPT 88305-TC) piece to Part A on a UB04.

Q21. Per CMS Change Request (CR)10075 for 2017, does the coinsurance and deductible continue to be waived for "moderate sedation" when furnished with the screening colonoscopy? Is it appropriate to append the modifier 33 or PT? Are these modifiers appended with CPT 45380 (diagnostic colonoscopy) or CPT 99153?
A21. Modifier PT (waives deductible for CPT 10000-69999) and is used for Medicare when the screening colonoscopy (or other colorectal cancer screening tests) turned diagnostic. HCPCS G0500 (moderate sedation by same physician performing endoscopic service that sedation supports; requiring presence of an independent trained observer to assist in monitoring; initial 15 minutes) and CPT 99153 (additional time if appropriate) turned diagnostic. The patient is still financially liable for the coinsurance. Modifier 33 identifies preventive services when the code is not identified as preventive.

HCPCS G0500 and CPT 99153 with the modifiers 33 or PT modifier will not be added until the Medicare October, 2017 release. If providers submit these code/modifier combinations prior to October, the claim lines will deny. For more information, see CMS CR8874 as it discusses the anesthesia for screening colonoscopies. Providers may either bill the appropriate screening or diagnostic HCPCS G0105 and HCPCS G0121 (depending on the patient risk) and the Ambulatory Surgical Center (ASC) or the hospital bills HCPCS G0500.

Last Updated Aug 14, 2018