Medical Review - JF Part B
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Medical Review Frequently Asked Questions (FAQs)
Q1: How do we make sure we are getting our Noridian Medicare letters related to our Targeted Probe and Educate (TPE), additional documentation request (ADR) and remittance advice?
A1: Make certain the address you have provided to Provider Enrollment/PECOS is correct. Refer to PECOS and the Identity and Access Management System. When the address is verified and you are expecting letters at that address, reach out to the person at that address so that the correspondence can be found and is passed on to you. Also enroll in the Noridian Medicare Portal (NMP). The portal allows users access to beneficiary and claim information. Please refer to Noridian Medicare Portal (NMP).
Q2: How am I able to tell if there is a Local Coverage Determination (LCD) for a certain procedure code, procedure code range or HCPCS code?
A2: Click on the link on the Noridian website for Local Coverage Determinations (LCD) for active LCDs. Refer to: Active LCDs . This will bring up a listing of all active LCDs with a search box to put in the CPT code(s) or HCPCS code(s) you would like to research.
Q3: Why can’t the anesthetist bill the peripheral nerve block they perform for postoperative pain management and when is it permissible to bill it separately?
A3: Prior to a surgery it is common practice that the anesthesiologist will perform a nerve block for the area that the surgeon is performing on to help with postoperative pain management. Even though this is common practice in the operative setting, does not mean that it is separate from the surgery billed or the anesthesiology service billed.
Per the National Correct Coding Initiative (NCCI) Chapter 2, it states, “postoperative pain management services are generally provided by the surgeon who is reimbursed under a global payment policy related to the procedure and shall not be reported by the anesthesia practitioner unless separate, medically necessary services are required that cannot be rendered by the surgeon. The surgeon is responsible for documenting in the medical record the reason that care is being referred to the anesthesia practitioner.”
The NCCI Chapter 2 explains when it is permissible to bill the peripheral nerve block separately, “Under certain circumstances, an anesthesia practitioner may separately report an epidural or peripheral nerve block injection (bolus, intermittent bolus, or continuous infusion) for postoperative pain management when the surgeon requests assistance with postoperative pain management.” It explains further, “A peripheral nerve block injection (CPT codes 64XXX) for postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the mode of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection, and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block injection. An epidural or peripheral nerve block injection (code numbers as identified above) administered preoperatively or intraoperatively is not separately reportable for postoperative pain management if the mode of anesthesia for the procedure is monitored anesthesia care, moderate conscious sedation, regional anesthesia by peripheral nerve block, or other type of anesthesia not identified above.”
Shifting our attention to the global surgical package, as payment for postoperative pain management is configured in that payment from Medicare, we will look at the Internet Only Manual (IOM) and the NCCI. The IOM Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 12, Section 40.1(A), “Components of a Global Surgical Package,” lists services included in the payment for surgical procedures, this list includes “Postsurgical Pain Management – By the surgeon.” The NCCI Chapter 1, General Correct Coding Policies for Medicare National Correct Coding Initiative Policy Manual, Sections B, C, F, G and O, all describe what is included in the global surgical package. Lastly, the NCCI Chapter 4, Section I. “General Policy Statements,” (20) states, “Medicare Global Surgery Rules prevent separate payment for postoperative pain management when provided by the physician performing an operative procedure. CPT codes 36000, 36410, 62320-62327, 64400-64489, and 96360-96379 describe some services that may be used for postoperative pain management. The services described by these codes may be reported by the physician performing the operative procedure only if provided for purposes unrelated to the postoperative pain management, the operative procedure, or anesthesia for the procedure.”
In conclusion, the peripheral nerve block performed for post operative pain management is included in the payment of the global surgical package. The peripheral nerve blockade performed for postoperative pain management, can be billed separately, in certain circumstances as described above and further detailed in the references provided. Therefore, it would be inappropriate billing practice to unbundle the peripheral nerve block from the surgery or anesthesia services performed unless the documentation clearly supports the certain circumstances as described in the NCCI. Refer to: NCCI Chapter 1, Chapter 2, Anesthesia Services, Section B and Chapter 4, Section I Medicare NCCI Policy Manual | CMS.
Also refer to: IOM Publication 100-04, MCPM Chapter 12, Section 40.1(A) Medicare Claims Processing Manual (cms.gov)
Last Updated Wed, 28 Dec 2022 17:39:59 +0000