Top Provider Questions – Medical Affairs
Click on an item to expand or Show All / Close All
- Q4158: Kerecis Omega3 Wound – Are providers required to submit invoices with claims?
-
When billing for Q4158 the providers do need to include invoice information in the notepad for Q4158. We need this information to include the following:
For electronic claims, report this information in the electronic Documentation Field (Loop 2300, NTE Segment (header level) or Loop 2400, NTE Segment (line level)).
If you are approved to submit paper claims, submit this information in Item 19 of the CMS-1500 claim form or provide a copy of the actual invoice.
- The name of the product, size, and the amount used must appear in the Documentation Field.
- If the charge matches the actual invoice cost, note "Actual Invoice Cost" in the Documentation Field. You are not required to submit invoice information with the claim; however, it must be available if requested.
- If you are submitting a charge greater than the actual invoice cost, please include the following information in the Documentation Field, using these abbreviations:
- Des = Description/Name of agent (e.g., Des=TC99m MDP)
- QS = Quantity shipped (e.g., QS=100 mci)
- TA = Total amount charged for quantity shipped (e.g., TA=$57.40)
- UP = Unit Price (e.g., UP = $0.57 per mci) (Optional)
- DG = Dosage given (e.g., DG=25 mci)
If no invoice information is supplied, we will not request the information but deny the line.
Reviewed 12/08/2021
-
- CGS website it states ancillary staff can take and record vital signs. It also states that physical exam is physician work. If the physician reviews the vital signs does that count as part of the physical exam?
-
The CMS Evaluation and Management Guidelines states the following: "Any part of the chief complaint or history that is recorded in the medical record by ancillary staff or the beneficiary does not need to be re-documented by the billing practitioner, and may instead review the information, update or supplement it as necessary, and indicate in the medical record that he or she has done so."
Page 9 states:
Of Note: The ROS may be recorded by ancillary staff, however, the physician or non-physician practitioner (NPP) must document the examination portion of the visit.
- Reference: CMS Evaluation and Management Services Guide
Reviewed 12/08/2021
-
- The new regulations stating "Date of service for HCPCS codes G0179 and G0180 must be submitted as the date physician/NPP saw the patient, not the date the physician/NPP signed the certification or recertification" fix the denials surrounding patients who were at the hospital or had passed when the physician signed the certifications. However, there are other complications with this change.
With the new regulation, I am looking up each patient to identify the DOS (within the cert period) to utilize as the claim DOS for the certification/recertification.
There have been instances where a provider within our practice did see the patient during the cert period, so I use that DOS as the claim DOS for the physician signature on the cert/recert. For the assisted living residents, the physician is not rounding as frequently at each facility, so the DOS of any provider is used for the physician submitted cert/recert.
However, there have been many instances where a provider within our practice DID NOT see the patient during the cert period at the time the cert/recert was submitted to the physician for signature. Many assisted living residents do not have as high acuity as nursing home patients, and thus may not have as frequent of visits. The certs should be signed timely. Most of these situations have provider visits the day prior (or a couple days prior) to the cert period, as our provider visit triggers the request for home health assistance. In these cases, the first date of the cert period is used as the claim DOS for billing the cert/recert signed by the physician.-
If the physician signing the certification is the physician who provided care for the patient while an inpatient, he/she should append a hospital place of service (POS 21) to the claim, not an office place of service (POS 11). Note that as part of an initial certification, reported with G0180, a face to face visit is required. This visit does not have to be the same date the certification is signed, but rather must take place no more than 90 days prior to, or within 30 days after the start of home health care. The certification must, in addition to other requirements, refer to the date of the face to face visit.
The certification must be completed prior to when the HHA bills for the SOC episode but should be completed at the time of, or shortly after the POC is developed.
Regarding recertification, we would like to add that Medicare does not require a specific date of service on the recertification claim (G0179). The G0179 code descriptor contains the words "patient not present" indicating that the physician performing a recertification does not need to see the patient. The component requirements which must be met to recertify the continued need for the home health benefit are noted in Pub. 100-2, Ch. 7, Sec. 30.5.2 and are noted below
At the end of the 60-day certification, a decision must be made whether to recertify the patient for a subsequent 60-days. An eligible beneficiary who qualifies for a subsequent 60-day certification would start the subsequent 60-day certification on day 61.
Under HH PPS, the plan of care must be reviewed and signed by the physician every 60 days unless one of the following occurs:
- A beneficiary transfer to another HHA; or
- A discharge and return to home health during the 60-day certification.
For recertification of home health services, the physician must certify (attest) that:
- The home health services are or were needed because the patient is or was confined to the home as defined in §30.1;
- The patient needs or needed skilled nursing services on an intermittent basis (other than solely venipuncture for the purposes of obtaining a blood sample), or physical therapy, or speech-language pathology services; or continues to need occupational therapy after the need for skilled nursing care, physical therapy, or speech-language pathology services ceased. Where a patient's sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan as defined in §40.1.2.2), the physician must include a brief narrative describing the clinical justification of this need as part of the recertification, or as a signed addendum to the recertification;
- A plan of care has been established and is periodically reviewed by a physician; and
- The services are or were furnished while the patient is or was under the care of a physician.
Since recertification does not require the physician to see the patient, the date of service is not limited to the date of any visit that may occur respectively of the fact that such visits are not necessary to recertify for a subsequent benefit period. CGS will be modifying our article accordingly.
Reference:
Reviewed 12/08/2021
-
- My question is related to observation billing past the 48-hour mark. Is it acceptable (compliant) to not automatically assign the GZ modifier and let the carrier determine what is not reasonable or necessary, or should the provider assign the GZ modifier for services after the 48-hour mark?
Which leads me to my next question, if Medicare truly deems observation status past 48 hours as not reasonable and necessary, does that mean services such as lab, radiology, etc. are also considered not reasonable or necessary when performed past the 48-hour mark?-
The CMS MLN Booklet: Medicare Advance Written Notices of Noncoverage states:
"If the beneficiary does not get written notice when required, the provider or supplier may be financially liable if Medicare denies payment".
The CMS IOM Benefit Policy Manual 100-02, Chapter 6, Section 20.6 A and C states:
"In most cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours. In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours" and
"If a hospital intends to place or retain a beneficiary in observation for a noncovered service, it must give the beneficiary proper written advance notice of noncoverage under limitation on liability procedures".
At any point during observation that it is determined that the beneficiaries care is not covered, an ABN should be issued.
As for "services such as lab, radiology, etc." which are related to non-covered services, the CMS IOM Benefit Policy Manual 100-02, Chapter 16, Section 10 explains that any services related to and required as a result of services which are not covered under Medicare are also excluded from coverage.
References:
- CMS Internet-only Manual, Pub. 100-04, Claims Processing Manual, Chapter 30
Reviewed 12/08/2021
-
- When billing for CPT 99239 (hospital discharge day management, more than 30 minutes), would the following phrase support the time documentation requirements in the note (in addition to the routine information provided in a discharge note): "More than 30 minutes was required to provide the discharge services."
-
Hospital discharge services are time-based codes utilized to show the total duration of time that a physician or qualified health professional spent to discharge a patient. Because these services are time-based, the provider must document the face-to-face time spent with the patient, family member, or surrogate and services must be reasonable and necessary. The total time spent in discharging the patient should be documented as opposed to just stating "more than 30 minutes". Providers are expected to follow both CPT and CMS guidelines/regulations and the services provided should be reasonable and necessary in accordance with Social Security Act § 1862(a)(1)(A), 42 U.S.C. § 1395y.
Reference:
- 2019 CPT® Manual, Professional Edition
- CMS Claims Processing Manual 100-04, Chapter 12, Section 100.1.4
- CMS Claims Processing Manual 100-04, Chapter 12, Section 30.6- 30.6.1 and 30.6.9.2
- CMS Evaluation and Management Services Guide
Reviewed 12/08/2021
-
- Would reviewing medications, determining that the dose is correct and continuing a medication qualify as prescription drug management?
-
The medical decision making to adjust any prescription medication when addressing and managing a problem or disease requires a higher complexity than refilling or continuing a medication; therefore, the documentation must be clear and concise when describing why a prescription medication was changed or continued. Simply providing a list of the patient's medications or stating 'reviewed' would not be considered prescription drug management complexity.
The provider may also choose to use qualifying factors of Total Time when choosing the E/M level of service.
Reference:
Reviewed 12/08/2021
-
- Is a discharge summary a required part of documentation for outpatient physical therapy clinics and physical therapy received in an inpatient hospital setting? If so, does a physical therapy discharge summary written by a PTA need to be co-signed by a PT, or does the physical therapy discharge summary need to be written by a PT?
-
A discharge summary is a required part of outpatient as well as inpatient physical therapy documentation and should be performed by the Physical Therapist. We would like to note that when a beneficiary is receiving services through an Inpatient Rehabilitation Facility (IRF), an interdisciplinary team approach is utilized as discussed in CMS Publication 100-04, Chapter 3, Section 140.1.1K:
"The IRF uses a coordinated interdisciplinary team approach in the rehabilitation of each inpatient, as documented by periodic clinical entries made in the patient's medical record to note the patient's status in relationship to goal attainment and discharge plans. The IRF must also ensure that team conferences are held at least once per week to determine the appropriateness of treatment."
References:
- CMS Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 220.3D-Documentaiton Requirements for Therapy Services – Progress Report
- CMS Medicare Benefit Policy Manual, Pub. 100-02, Chapter 1, Section 110.1.3
- CMS MLN Medicare Provider Compliance Tips
Reviewed 12/08/2021
-