Top Provider Questions – Medical Review
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- What DOS should I use for technical/professional components when each service can be billed separately?
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- The technical component is date patient received service
- When the technical component is reported separately, the service may be identified by adding the Modifier TC to the usual procedure number.
- Professional component is date review and interpretation is completed
- When the physician component is reported separately, the service may be identified by adding the Modifier 26 to the usual procedure number
Reference: MLN Matters SE17023
Reviewed 9/30/2021 - The technical component is date patient received service
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- How do I report Federally Mandated Visits (CPT Codes 99307-99310)?
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Reporting Federally Mandated Visits (CPT Codes 99307-99310)
CPT codes 99307-99310 (Subsequent Nursing Facility Care, per day) shall be used to report federally mandated physician visits and other medically necessary visits.
The initial visit in a skilled nursing facility (SNF) and nursing facility (CPT 99304-99306) must be furnished by a physician except as otherwise permitted as specified in the Code of Federal Regulations (42 CFR 483.40(c)(4)). Qualified Non-Physician Practitioners (NPPs) may provide federally mandated visits (after the initial visit by the physician and as permitted under the Long Term Care Regulations).
Medicare will pay for federally mandated visits that monitor and evaluate residents:
- At least once every 30 days for the first 90 days after admission, and
- At least once every 60 days thereafter.
- These visits are considered timely if they occur no later than 10 days before or after the date the 30/60 day visit was required.
Report medically necessary E/M visits using CPT codes 99307-99310 even if they are provided prior to the initial visit by the physician.
Documentation should consist of the following:
If the primary reason for the physician/NPP visit is the performance of a Federally Mandated visit, the documentation should reflect the following:
- The Chief Complaint or rationale for the visit in the clinical note should reflect the visit that date was for a federally mandated or 30- or 60-day visit.
- The documentation must support a review of the resident's total program of care was performed. This must include:
- A review of medications
- A review of current treatment plan
- Review of all patient diagnoses and current status of each.
- Write, sign, and date progress notes at each visit.
- The documentation and/or time listed in note should support the level of care billed.
The federally mandated E/M visit may serve also as a medically necessary E/M visit if the situation arises (i.e., the patient has health problems that need attention on the day of the scheduled mandated physician E/M visit.) When this occurs:
- The Chief Complaint or rationale for the visit indicate both the medical necessity for the visit as well as indicate this was a federally mandated visit.
- The documentation must support the level of care billed for medical necessity.
- The documentation must support all the criteria for a federally mandated visit:
- A review of medications
- A review of current treatment plan
- Review of all patient diagnoses and current status of each.
- Write, sign, and date progress notes at each visit.
- The documentation and/or time listed in note should support the level of care billed.
An annual nursing facility assessment visit code may substitute as meeting one of the federally mandated physician visits if the code requirements for CPT code 99318 are fully met and in lieu of reporting a Subsequent Nursing Facility Care, per day, service (CPT codes 99307 – 99310). The CMS Medicare Claims Processing Manual (chapter 12, section 30.6.13.B) specifies that the annual nursing facility assessment visit "shall not be performed in addition to the required number of federally mandated physician visits."
Ohio Regulations regarding medical supervision:
- Each resident of a nursing home shall be under the supervision of a physician.
- Each resident of a nursing home shall be evaluated by a physician or other licensed health professional acting within the applicable scope of practice, at least once every thirty days for the first ninety days after admission or three evaluations.
- After this period, each resident of a nursing home shall be evaluated by a physician or other licensed health professional acting within the applicable scope of practice at least every sixty days, except if the attending physician documents in the medical record why it is appropriate. The resident may be evaluated no less than once every 120 days.
- The evaluations required by this rule shall be made in person. In conducting the evaluation, the physician or licensed health professional shall solicit resident input to the extent of the resident's capabilities.
- The physician or licensed health professional shall write a progress note after each evaluation depicting the current condition of the resident based upon consideration of the physical, mental and emotional status of the resident.
- A physician or licensed health professional visit is considered timely if it occurs no later than10 calendar days after the date the visit was required.
Kentucky Regulations regarding medical supervision:
- The health care of each patient shall be under supervision of a physician who, based on an evaluation of the patient's immediate and long-term needs, prescribes a planned regimen of medical care which covers indicated medications, treatments, rehabilitative services, diet, special procedures recommended for the health and safety of the patient, activities, plans for continuing care and discharge.
- Patients shall be evaluated by a physician at least once every 30 days for the first 90 days following admission. Subsequent to the 90th day following admission, the patient shall be evaluated by a physician every 60 days. There shall be evidence in the patient's medical record of the physician's visits to the patient at appropriate intervals.
- There shall be evidence in the patient's medical record that the patient's attending physician has made arrangement for the medical care of the patient in the physician's absence.
- The facility shall have arrangements with one (1) or more physicians who will be available to furnish necessary medical care in case of an emergency if the physician responsible for the care of the patient is not immediately available.
References:
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 30.6.13
- Code of Federal Regulations: 42 CFR 483.40(c)(1)
- Ohio Regulation 3701-17-13 Medical Supervision
- CGS Documentation Checklists for CPT codes 99307, 99308, 99309, and 99310:
Reviewed 9/30/2021
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- Please clarify coding for CPT Code 94620: Pulmonary Stress Testing
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Please see the pulmonary stress test coding revisions in the 2021 CPT Book. Service code 94620 has been deleted; to report pulmonary stress testing, use 94618. Please note, only one unit of the code should be reported on any given date of service.
Reviewed 9/30/2021
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- What types of tests may require a technical assessment (TA)?
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- All lab developed tests (LDTs) which are performed using either established or novel technology whose clinical utility is unestablished
- Any molecular or genetic testing whose clinical and analytical validity needs to be established
- Any tests using modified versions of FDA registered kits
- Any new molecular or genetic technological testing platform
- Any genetic or molecular target whose clinical utility is unestablished
- Any new test LDT within the MolDX code range that requires a TA
- Include Next Generation Sequencing (NGS) technology
Reviewed 9/30/2021
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- Is partial excision of tibia bone is outside the scope of a podiatrist?
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With regard to Podiatrist services, each state in which the podiatrists is licensed provides a scope of practice, some states feel that a podiatrists can treat the foot and structures that support the foot, such as the ankle. In order to determine the service being provided is within this scope of practice CGS will review documentation via the appeal process.
Reviewed 9/30/2021
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- When facilities report waste for drugs/biologicals must they now use the JW modifier?
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For single dose vials, facilities must report the JW if they want to be reimbursed for the wastage. Refer to the "Important: JW Modifier Use Change Effective July 1, 2016" article for additional information.
Reviewed 9/30/2021
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- What are example of measurable goals for chiropractic services?
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Measureable goals should be descriptive;
- Not Measureable: "return to pre-injury status"
- Measureable:
- Sit at a desk pain free for 6 hours
- Lift 25 pounds without pain
- Stand for 2 hours without pain
- Have active flexion of the lumbar region of >65 degrees without pain
- Not Measureable: "ROM reduced"
- Measureable: Flexion is 15 degrees with normal being 45 degrees
- Not Measureable: moderate pain
- Measureable: Pain is 8/10 on a VAS
Reviewed 9/30/2021
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- Is the physician attesting that he dictated the note to the scribe and signing his name sufficient?
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There are specific rules for scribes. Please refer to the recently updated CGS article, Non-Physicians Acting as Scribes.
Reviewed 9/30/2021
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- I'm having trouble with moderate sedation, in particular the use of CPT 99153. Can you provide some assistance?
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CGS recently published an article to assist providers with this code. Please refer to the Clarification of CPT Code 99153 CGS article.
Reviewed 9/30/2021
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- If a patient has a psych diagnosis and is unwilling to participate in the physical exam can it be counted as a comprehensive exam?
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If the physician is unable to obtain a ROS from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history. If properly documented, the provider may count this portion of the visit as Comprehensive. Conversely, Examination should be based upon the number of body areas the provider can observe without the cooperation of the patient (e.g. skin color or lesions, diaphoresis, breathing effort etc..) The practitioner may not score a comprehensive examination unless the required elements in the descriptors are met.
Effective January 1, 2021, the 1995 and 1997 guidelines will no longer be used for office or other outpatient E/M services (99202 – 99215); rather, the provider may choose to use Medical Decision Making or Total Time in determining the appropriate level of service code.
Reviewed 9/30/2021
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- What are the billing guidelines for Cecostomy Irrigation?
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Refer to the recently published article, Cecostomy Irrigation System Billing Guidelines article for assistance.
Reviewed 9/30/2021
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- When billing for an assistant at surgery, is it best practice for the surgeon to specify in the body of the operative note what the assistant actually did, as well as make it clear in the "indications" paragraph of the note why an assistant was necessary?
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It is important to document the skills which are needed above and beyond what ancillary staff can provide. It is insufficient to simply list the assistant's name in the operative report.
References:
- MM6213, Payment of Assistant at Surgery Services in a Method II Critical Access Hospital (CAH)
- Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 20.4.3
- Medicare Claims Processing Manual, Pub. 100-04, Chapter 4, Section 250.9
Reviewed 9/30/2021
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- When billing for Prolonged Services are we required to document time?
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Documentation is required to be in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services that you bill.
You MUST appropriately and sufficiently document in the medical record that you personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. Best practice includes documenting the start and end times of the visit, along with the date of service.
The above information can be found in the MLN Matters Article MM5972 "Prolonged Services (Codes 99354 and 99359)."
MLN Matters: MM12071 – Summary of Policies in Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List.
Reviewed 9/30/2021
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- What could be reasons we are receiving diagnosis denials when following the coding/policy article?
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We have seen an increase of denials for this situation and after reviewing data the reason for the denial is one of the following.
- Use of a diagnosis that is in the billing and coding policy article but not related to the service performed.
- In some billing and coding articles there are ICD-10 groups that are specific for certain CPT codes but not related to all CPT codes in the article. The ICD-10 group paragraph will have the CPT code that group of diagnoses supports medical necessity.
- Use of only one ICD-10 code when there is a dual diagnosis requirement.
- If a billing and coding article has a dual diagnosis requirement, this will be indicated in the ICD-10 group paragraph with an indication of primary diagnosis and the group below with secondary diagnosis.
- Use of an unspecified diagnosis.
- In many cases, CGS does not include the unspecified ICD-10 code in a series because the other codes are more specific. There are times an unspecified code may be included so we ask that you review the billing and coding article to verify the unspecified code is listed as one that supports medical necessity.
Reviewed 9/30/2021 - Use of a diagnosis that is in the billing and coding policy article but not related to the service performed.
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- Can you explain how CGS prices skin substitutes and what Place of Service is allowable?
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If the skin substitute has been cleared by the FDA through 501 process it is covered and reimbursement is based on the invoice information given on the claim in the notepad if CMS does not price, provided it is medically reasonable and necessary.
REFERENCES:
- Local Coverage Article: Billing and Coding: Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (A56696)
- Local Coverage Determination (LCD): Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (L36690)
Reviewed 9/30/2021
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- Can an Anesthesiologist Assistant (AA) can be billed without medical direction (using the QZ modifier) if the anesthesia service is performed without medical direction, just like a Certified Registered Nurse Anesthetist (CRNA)?
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As per Medicare Claims Processing Manual Chapter 12, Section 140.3.3, modifiers QZ and QX should be used as follows.
- QX = AA's and CRNA's with medical direction
- QZ = CRNA's without medical direction
Reviewed 9/30/2021
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- Can we bill a second appointment for chemotherapy education provided by an RN prior to the start of the chemo and is there a difference between oral and IV medication?
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There is not a 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.
Reviewed 9/30/2021
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- On documentation for subsequent Evaluation & Management (E/M) visits when 2 out of the 3 key elements are required, is it necessary/required that one of the elements be "examination" or can 2 of the 3 by "history and decision making?"
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CPT guidelines indicate that E/M codes are used to bill for "face-to-face" services rendered by a clinician. For subsequent visits, CPT guidelines indicate that 2 out of 3 elements must be present to support the level of service submitted; it does not state which elements must be present. The face to face encounter must be clear so that a medical reviewer can be confident a face-to-face encounter occurred.
NOTE: It is essential providers understand the importance of the face-to-face encounter and justify it when 2 of the 3 key elements are history and decision making. It must be crystal clear in the documentation that you performed those 2 elements face-to-face or the service may be denied upon review. Please note: CGS considers these situations to be uncommon.
Effective January 1, 2021, the 1995 and 1997 guidelines will no longer be used for office or other outpatient E/M services (99202 – 99215); rather, the provider may choose to use Medical Decision Making or Total Time in determining the appropriate level of service code.
Reviewed 9/30/2021
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- Can we bill drug and drug administration on separate claims?
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Drug administration code must be accompanied by a drug. Refer to the Drug Administration Reminder article for additional information.
Reviewed 9/30/2021
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