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2 DOCUMENTING CHEST X-RAYS AND DXA BONE DENSITY STUDIES Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC) Provider Outreach and Education December 13, 2016

3 DOCUMENTING CHEST X-RAYS AND DXA BONE DENSITY STUDIES Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC) Provider Outreach and Education December 13, 2016

4 December Using On24 Widgets Adjust volume using your computer speakers, headset or the ON24 Media Player Use your mouse to point, click, and open a widget

5 December Adjusting Your ON24 Screen View Sometimes you may want to minimize or maximize one screen to view another. Some computers are set up to open new windows in the Full Screen view. This view disables all the ribbons and toolbars and only provides you with minimal options. If you are unable to see portions of today s session, press the F11 key to switch from Full Screen Viewing.

6 December Disclaimer The information provided in this presentation was current as of 12/13/2016. Any changes or new information superseding the information in this presentation will be provided in articles and resources with publication dates after 12/13/2016 posted on our website at Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) and the Railroad Retirement Board (RRB) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. CPT only copyright 2016 American Medical Association. All rights reserved. Copyright 2016 Ame r ican De ntal Association ( A DA). All rights re se rve d.

7 December What is Railroad Medicare? Railroad Retirement Acts of the 1930s First retirement system for nongovernmental workers Provisions created in 1965 to provide the benefits of the Medicare program to railroad employees and their dependents The Railroad Retirement Board (RRB) works with CMS to ensure Railroad beneficiaries receive the same benefits as their SSA Medicare counterparts Part B claims for Railroad Medicare beneficiaries are processed nationally by Palmetto GBA in Augusta, Georgia as the Railroad Retirement Board Medicare Specialty Administrative Contractor (RRB SMAC) Part A and DMEPOS claims for Railroad Medicare beneficiaries are processed by jurisdictional Medicare Administrative Contractors (MACs)

8 December Objectives At the end of this presentation you will be familiar with: Medicare Part B coverage guidelines for chest x-rays and DXA Bone Density Studies Medicare s documentation requirements for chest x-rays and bone mass measurement studies Medical review of these diagnostic radiology tests

9 December Agenda Overview of Medical Review and Additional Documentation Requests (ADRs) Coverage of Diagnostic Test Billing Codes and Modifiers Documentation of Diagnostic Tests Chest X-Ray Bone Mass Measurements (DXA) Resources

10 December MEDICAL REVIEW

11 December Radiology Codes Under Review CPT Radiologic examination, chest, single view, frontal CPT Radiologic examination, chest, two views, frontal and lateral CPT Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) Billed global or with 26 or TC modifier Billed in any place of service CPT only copyright 2016 American Medical Association. All rights reserved. Copyright 2016 American Dental Association (ADA). All rights reserved.

12 December Railroad Medicare Medical Review Program Supports the goals of the CMS Medical Review program Proactively identifies patterns of potential billing errors concerning coverage and coding Reviews data analysis reports, complaints or inquiries Takes action to prevent and/or address the identified errors Develops and conducts education The goal of the medical review (MR) program is to reduce payment errors by preventing the initial payment of claims that do not comply with Medicare s coverage, coding, payment, and billing policies.

13 December Railroad Medicare Prepayment Medical Review Performed as a result of vulnerabilities determined by data analysis Performed on claims prior to payment Results in an initial determination Service specific (CPT/HCPCS) Widespread Additional Documentation Requests (ADRs) are sent to request supporting documentation

14 December Prepayment Review Process Claim is selected for review. Additional Documentation Request (ADR) letter is issued. You must respond within 45 calendar days. Medical Review will make a determination within 30 calendar days of receiving requested documentation. Claim will be denied on the 46 th day is a response is not received. Claim will be denied on the 46 th day if a response is not received.

15 December Medical Record Requests Medicare contractors are authorized to collect medical documentation by the Social Security Act. Section 1833(e), states: No payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period. These requirements are also outlined in Section 1815(a) of The Act. Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA) Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review Documentation will be requested from the rendering provider

16 December How to Respond to an ADR Provide the documents listed on the ADR and any related physician s orders Make sure the provider s signature is legible or include a signature log or attestation if necessary Include a copy of the ADR letter with your documents When returning ADR responses for multiple claims, be sure to pair each ADR letter with the corresponding documentation Include a completed Medical Review ADR Response Cover Sheet for each ADR letter/claim

17 March Methods of Responding Upload your documentation online through eservices Submit your documentation via the esmd (Electronic Submission of Medical Documentation) mechanism. See for details. Fax your responses to Mail documents or an encrypted CD/DVD Mail responses to: Palmetto GBA Railroad Medicare Medical Review PO Box Augusta, GA 30999

18 December Granular Denial Letters Claim Review Decision and Education Letter Sent when claim is denied by Medical Review Explains why claim was denied Outreach and Education may contact providers to discuss review findings

19 December Non-Response to ADRs Represents greatest number of claim denials No response received Response received more than 45 days after date of request

20 December Common Denials Medical review is unable to determine medical necessity of the service with documents submitted o Documents received did not include a signed order or signed progress note with intent to order o Orders submitted do not indicate the medical necessity for the test Medical review unable to determine the test was performed o Missing the interpretive report of the results of the test o Missing signature of provider who interpreted the results

21 December Medical Review Webcast Recorded presentation available Look for Webinars & Workshops on our Learning & Education Page R

22 December MEDICARE COVERAGE OF DIAGNOSTIC TESTS

23 December Diagnostic Radiology Resources IOM , Medicare Claims Processing Manual, Chapter 13 Radiology Services and Other Diagnostic Procedures IOM , Medicare Benefit Policy Manual, Chapter 15 Covered Medical and Other Health Services. Section 80 - Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests

24 December Medicare Coverage of Imaging Services This fact sheet provides basic information about Medicare coverage, billing and payment of all imaging services, to include radiology and non-radiology diagnostic imaging and image-guided procedures. MLN ICN / June

25 December Description of Diagnostic Tests A service is diagnostic if it is an examination or procedure which is performed on the patient (or samples derived from a patient) to obtain information to aid in the assessment of a medical condition or the identification of a disease. Medicare Part B covers diagnostic tests ordered by a physician or qualified NPP for the purpose of diagnosing or treating a patient s medical condition.

26 December Diagnostic Chest X-rays Diagnostic chest x-rays are radiologic studies for the purpose of diagnosis of illness or condition which manifest symptoms within the chest cavity. Common diagnoses tested for are: Respiratory system dysfunction o Pneumonia, COPD, masses, etc. Cardiac system dysfunction o Hypertrophy, tamponade, etc.

27 December Non-Covered Chest X-Rays Non-covered Routine services oroutine x-rays with Annual Wellness Visit or yearly physical oroutine pre-surgical x-rays Services that are not reasonable and necessary Tests not ordered by the treating provider

28 December Bone Mass Measurements (BMMs) Bone Mass Measurement means a radiologic, radioisotopic, or other procedure that: Is performed to: identify bone mass detect bone loss determine bone quality Is performed with either a bone densitometer (other than singlephoton or dual-photon absorptiometry) or a bone sonometer system that has been cleared for marketing for BMM by the Food and Drug Administration (FDA) under 21 CFR part 807, or approved for marketing under 21 CFR part 814, and Includes a physician s interpretation of the results.

29 December BMM - Conditions for Coverage Medicare covers BMM under the following conditions: Is ordered by the physician or qualified NPP who is treating the beneficiary following an evaluation of the need for a BMM and determination of the appropriate BMM to be used. Is performed under the appropriate level of physician supervision Is reasonable and necessary for diagnosing and treating the condition of a beneficiary Is performed with a dual-energy x-ray absorptiometry system (axial skeleton), in the case of an individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy, Is performed with a dual-energy x-ray absorptiometry (DXA),(DEXA) system (axial skeleton) for monitoring tests or confirmatory testing if the initial scan was not DXA.

30 December BMM - Who May be Covered To be covered, a beneficiary must meet at least one of the five conditions listed below: A woman who has been determined to be estrogen-deficient and at clinical risk for osteoporosis An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months. An individual with primary hyperparathyroidism. An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.

31 December BMM - Frequency Medicare pays for a screening BMM once every 2 years (at least 23 months have passed since the month the last covered BMM was performed). More frequently if medically necessary Examples include, but are not limited to, the following medical circumstances: o Monitoring beneficiaries on long-term glucocorticoid or steroid therapy of more than 3 months. o Confirming baseline measurements to permit monitoring of beneficiaries in the future.

32 December Non-Covered BMM Non-covered Routine services oscreening measurements more than once every two years oroutine screenings on patient s who do not qualify under one of the diagnosis guidelines Tests not ordered by the treating provider

33 December BILLING AND CODING

34 December CPT Codes CPT Codes for chest x-ray Radiologic examination, chest, single view, frontal Radiologic examination, chest, two views, frontal and lateral CPT Codes for bone mass measurement Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) These CPT codes are MPFSDB PC/TC 4 global codes which can be split into professional (PC) and technical (TC) components. Use appropriate modifier if not billing for the full global procedure CPT only copyright 2016 American Medical Association. All rights reserved. Copyright 2016 American Dental Association (ADA). All rights reserved

35 December Technical Component TC The TC is for all non-physician work, and includes administrative, personnel and capital (equipment and facility) costs, and related malpractice expenses. Modifier TC is used with the billing code to indicate that the technical component is being billed. CPT only copyright 2016 American Medical Association. All rights reserved. Copyright 2016 American Dental Association (ADA). All rights reserved

36 December Professional Component PC The PC of a service is for physician work interpreting a diagnostic test or performing a procedure. It includes indirect practice and malpractice expenses related to that work. Modifier 26 is used with the billing code to indicate that the PC is being billed. CPT only copyright 2016 American Medical Association. All rights reserved. Copyright 2016 American Dental Association (ADA). All rights reserved

37 December Global Billing Billing globally for services that can be split into PC and TC components is only possible when: The PC and TC components are furnished by the same physician or supplier entity The PC and TC are performed in the same Medicare Physician Fee Schedule (MPFS) locality When a physician performs a diagnostic test under arrangement to a hospital and the test and the interpretation are not separately billable, the interpretation cannot be billed by the physician. In this scenario, the hospital is the only entity that can bill for the diagnostic test which encompasses the interpretation. There is no POS code for the interpretation since a physician claim is not generated.

38 December Radiology Coding Place of Service The PC and TC of diagnostic services are often furnished in different settings The physician and other supplier should use the place of service (POS) assigned to the same setting in which the beneficiary received the face-toface service Exceptions to this face-to-face provision/rule in which the physician always uses the POS code where the beneficiary is receiving care, regardless of where the beneficiary encounters the face-to-face service, are when: The patient is a registered inpatient of a hospital The patient is a registered outpatient of a hospital In these cases, the POS billed should always be the setting in which the patient is receiving inpatient or outpatient hospital care CMS Change Request (CR) 7631

39 December Repeat Procedure Modifiers It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service on the same day. Modifiers 76 - repeat procedure by same physician 77 - repeat procedure by another physician CPT only copyright 2016 American Medical Association. All rights reserved. Copyright 2016 American Dental Association (ADA). All rights reserved

40 December Chest X-Rays for Emergency Room Patients Emergency Room X-Rays Medicare normally pays for only one interpretation of an x-ray furnished to an emergency room patient. In the event that the claim is for both the emergency room treating physician and the radiologist, documentation may be submitted to support that interpretation results were used in the diagnosis and treatment of the patient. The second interpretation may be identified with modifier 77 CPT only copyright 2016 American Medical Association. All rights reserved. Copyright 2016 American Dental Association (ADA). All rights reserved

41 December DOCUMENTATION

42 December Documentation Requirements Documentation elements to include when responding to an ADR for a diagnostic radiology test: The Order Documentation on Medical Necessity Report of Results Signatures

43 December Example Order for Diagnostic Test An acceptable order may come in many different forms or formats. Examples are: Handwritten or electronically submitted signed document from the treating provider Signed progress or exam note with the plan to order the specific test Documented telephonic communication from the treating physician, requesting test for diagnostic purposes

44 December Elements of An Acceptable Order Order must include certain elements : Order date Patient identification information The specific test ordered Clearly document the intent and purpose for imaging Legible name and signature or provider

45 December Signature on Orders and Reports Signature Examples: To meet guidelines there must be a legible form of the name and credentials. Printed or typed names must be accompanied by Initials or Signature of provider. Electronic signatures must indicate it is an electronic signature.

46 December Signature Requirements on Orders and Reports Medicare does not accept retroactive orders. If an order for tests is unsigned, you may submit signed progress notes showing intent to order the tests. The progress notes must specify what tests you ordered.

47 December Medical Necessity of Test Medicare benefits rest on medical necessity Per 42 CFR (d)(2)(i), "The physician...who orders the service must maintain documentation of medical necessity in the beneficiary's medical record. If the medical necessity is not supported on the order, this information should be available from the referring provider and must be submitted in addition to the documented test results or reports

48 December Medical Necessity of Test Medical necessity Is evidenced by: Utilization of the appropriate billing code Applicable modifier Clinical documentation supporting the diagnosis and necessity.

49 December Diagnostic Test Report The Diagnostic Test Report: Is the interpretation of the test results Supports the services billed The test report should address: Relative Clinical Issues Available Comparative Data Specific Test Findings The test report must include: Signature of interpreting physician

50 December Documentation Checklist Chest X-Ray

51 December Documentation Checklist BMM

52 December RESOURCES

53 December MLN Resources The Medicare Learning Network Page

54 December MLN Connects National Provider Calls Free educational conference calls held by CMS for the Medicare providers and suppliers to educate and inform about new policies and/or changes to the Medicare program Prior registration is required Subscribe to weekly MLN Connects Provider enews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements

55 December CMS Open Door Forums CMS sponsors regularly scheduled Open Door Forums providing opportunities for live dialogue between CMS and the stakeholder community at large Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website CMS Open Door Forums page

56 December RRB SMAC Resources

57 December RRB SMAC Resources

58 December Visit MLN articles from the Centers for Medicare & Medicaid Services (CMS) Articles and FAQs by topic Self-Services Tools eservices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup Reason/Remark Code Lookup

59 eservices Claim Status Eligibility Remittances Appeals Submission of Requested Medical Records Greenmail notification of Pending ADR Requests Greenmail edelivery Responses

60 December Respond to ADRs in eservices Respond to Medical Review ADR and postpayment review notification letters through eservices using the MR ADR Response secure eform Attach an unlimited number of PDF files to each form. Each attachment can be up to 40 MB. The total size of all attachments on each ADR eform can be no more than 150 MB. Track submission of your ADRs Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare Enroll for eservices at

61 December Greenmail through eservices Receive edelivery of: Medical Review ADRs for prepayment reviews Overpayment Demand letters Medicare Redetermination Notices for your appeal requests Responses to General Correspondence inquiries Provider Administrators may select the edelivery option to receive: eletters in eservices inbox notification of new eletters

62 December eservices Resources

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64 December Railroad Medicare Contacts RAILROAD MEDICARE RESOURCES Provider Contact Center Railroad EDI / eservices Medicar e Telephone Reopenings Homepage Provider Enrollment Palmetto GBA Listserv Select Listservs from top tool bar Contact Us By Medicare.Railroad@PalmettoGBA.com Interactive Voice Response (IVR) eservices Under Forms/Tools Palmetto GBA Railroad Medicare CMS Listserv PO Box Augusta, GA 30999

65 December Questions?

66 December Thank you! Questions about this webcast? Provider Contact Center