Volume 13, Issue 2 April 25, 2013 Coding & Billing for Prospective Payment Systems April 2013 Hospital OPPS Update April 2013 ASC Update Q & A CMS Ruling: Rebilling for Denied Inpatient Claims Page 1
Volume 13, Issue 2 April 25, 2013 CPT Copyright 2012 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. Table of Contents: April 2013 Hospital OPPS Update Recovery of Annual Wellness Visit Overpayments 3 8 Since 1989 HMI Corporation, a Healthcare Management Company, a subsidiary of Healthcare Provider Services, has been assisting acute care, teaching, critical access, long term care, nursing home, home health, and skilled nursing facilities, as well as physician groups, with clinical reimbursement through accurate coding and billing for all financial classes as well as maintaining compliance with Federal payers. HMI s consultant specialists perform compliance reviews, billing, and coding medical reviews, as well as other revenue improvement services, utilizing the provider s chargemaster. HMI also provides physician education to strengthen the medical staff's E/M coding for compliance and to improve reimbursement. CMS Ruling: Part A to Part B Rebilling for Denied Inpatient Revised and Clarified Place of Service (POS) Coding Instructions Outpatient Therapy Functional Reporting Non-Compliance Alerts April 2013 ASC Payment System Update 9 10 11 12 Question and Answer 15 HMI offers a full-service program to assist providers in positioning themselves to meet federal compliance guidelines, with an emphasis on PPS reimbursement. This process also includes inpatient and outpatient record review, on-going chargemaster maintenance, remote chargemaster services, interim chargemaster coordinator coverage, remote contract coding, and on-site education/training of clinical staff and physicians. Our twenty-three year success has been primarily founded on facilitating quality consulting service, on-going accountability through management plan objectives and guaranteed service based on our ability to deliver results. 155 Franklin Road Suite 100 Brentwood, TN 37027 Phone: 615-661-5145 Fax: 615-661-5147 Email: info@hmi-corp.com Website: www.hmi-corp.com Page 2
CMS Transmittal 2664 issued March 1, 2013 with the April quarterly updates; the following is a summary of the changes contained in this transmittal. I. Changes to Device Edits for April 2013. For the most current device edits can be located at http://www.coms.gov/medicare/medicare-fee-for -Service-Payment/HospitalOutpatientPPS/ II. New Services April 2013 Update of the Hospital Outpatient Prospective Payment System (OPPS) The following new services are payable under OPPS effective April 1, 2013: Effective Date SI APC Short Descriptor Long Descriptor Payment Minimum Unadjusted Copayment C9734 4/1/2013 S 0067 U/S trtmt, not leiomyomata Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with or without magnetic resonance (MR) guidance $3,300.64 $660.13 C9735 4/1/13 T 0150 Anoscopy, submucosal inj Anoscopy; with directed submucosal injection( s), any substance $2,365.97 $473.20 Note: Use code C9735 for the administration/injection for Solesta and should only be reported with code L8605. Page 3
III. Payment Reduction for Single Session Cobalt-69 Based Stereotactic Radiosurgery (SRS) As per Section 634 of the American Taxpayer Relief Act of 2012, CMS is reducing the payment amount for Cobalt-60 based SRS as described by CPT code 77371 to an amount equal to the payment amount for the linear accelerator based SRS procedure as described by code G0173. This reduction does not apply to rural hospitals and sole community hospitals. CPT/ Code 77371 G0173 Long Descriptor Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multisource Cobalt 60 based Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session April 2013 APC 0127 April 2013 Payment Rate Rural Hospitals and other excepted Hospitals All Other Hospitals $7,911 $3,301 0067 $3,301 IV. Inpatient Telehealth Pharmacological Management ( Code G0459) January 1, 2013 CMS established code G0459 to track remotely-delivered inpatient pharmacological management services provided to patients with mental disorders in rural hospitals. G0459 was not published in the Addendum B for CY 2013 OPPS/ASC final rule of November 1, 2012. The following table provides the short and long descriptors as well as the OPPS status indicator for this service. Code G0459 Short Descriptor Long Descriptor SI APC Telehealth inpt pharm mgmt Inpatient telehealth pharmacologic management, including prescription, use, and review of medication with no more that minimal medical psychotherapy B N/A Page 4
V. Billing for Drugs, Biologicals, and Radiopharmaceuticals A. Drugs and Biologicals with Payments Based on Average Sales Price Effective April 1, 2013 The April updates for Addendum A and B can be found at the following links: Addendum A http://www.cms.gov/medicare/medicare-fee-for-service-payment/ HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates-Items/April-2013- Addendum-A.html Addendum B http://www.cms.gov/medicare/medicare-fee-for-service-payment/ HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates-Items/April-2013- Addendum-B.html B. Drugs and Biologicals with OPPS Pass-through Status Effective April 1, 2013 Below are the five drugs and biological that were granted OPPS pass-through status effective April 1, 2013. Code Long Descriptor APC Status Indicator Effective 4/1/13 C9130* Injection, immune globulin (Bivigam), 500 mg 9130 G C9297* Injection, omacetaxine mepesuccinate, 0.01 mg 9297 G C9298* Injection, orciplasmin, 0.125 mg. 9298 G J7315 Mitomycin, ophthalmic, 0.2 mg 1448 G Q4127 Talymed, per square centimeter 1449 G Note: Codes with * indicate a new code effective April 1, 2013 Additional instruction was given for the use of Codes C9298 and J3175 as follows: C9298 Jetrea is packaged as a sterile single use vial containing 0.5 mg ocriplasmin in a 0.2mL solution for intravitreal injection. Use of the contents of an entire vial to one patient as per the FDA labeled approval would result in the reporting of 4 units of C9298 on a claim. J7315 Should only be used for Mitosol and not for the compounded mitomycin or other forms of mitomycin. Page 5
C. Flucelvax While Flucelvax (Influenza virus vaccine) was assigned a to CPT code 90661 since January 1, 2008 with a status indicator of E, it was not FDA approved until November 20, 2012. The OPPS status indicator has now been changed to L (Influenza Vaccine; Pneumococcal Vaccine) and will be reflected in the April 2013 I/OCE. The table below provides the descriptors and new OPPS status indicator for CPT code 90661. CODE 90661 Short Descriptor Flu vacc cell cult prsv free Long Descriptor Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use APC NA Status Indicator Effective 4/1/13 L D. Updated Payment Rates for Certain Codes Effective January 1, 2013 through March 31, 2013 The January 2013 OPPS Pricer had the incorrect payment rates for codes J9263 and Q4106. The table below indicates the corrections that have been installed with the April 2013 update and is effective for services furnished on January 1, 2013 through March 31, 2013. Code Status Indicator APC Short Descriptor Corrected Payment Rate Corrected Minimum Unadjusted Copayment J9263 K 1738 Oxaliplatin $3.95 $0.79 Q4106 K 1245 Dermagraft $42.55 $8.51 Page 6
VI. Changes to OPPS Pricer Logic As mentioned earlier effective April 1, 2013, the OPPS Pricer will respond to hospital billed lines that contain the stereotactic radiosurgery services reimbursed under APC 0127 and reduce the reimbursement to APC 0067. Please see Section III above for specifics. VII. Coverage Determinations CMS is stating in this transmittal that the fact that a drug, device, procedure or service is assigned a code and payment rate does not imply that it is covered by the Medicare program. This only indicates how the procedure, product or service may be paid if it were covered by the program. To read Transmittal 2264 please go to: http://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r2664cp.pdf To read MLN Matters MM8228 please go to: http://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/ Downloads/MM8228.pdf Page 7
Recovery of Annual Wellness Visit (AWV) Overpayments On April 11, 2013 CMS rescinded and replaced Transmittal 1190 with Transmittal 1209 to provide further instructions regarding the recovery of Annual Wellness Visit (AWV) overpayments. For providers that submitted claims to Part B MACs or Medicare Carriers the contactors will be using the overpayment recovery procedures as described in the Medicare Financial Management Manual, Chapter 3, Overpayments and Chapter 4, Debt Collection (http://www.cms.gov/regulations-and-guidance/guidance/ Manuals/Downloads/fin106c03.pdf). They also noted that the beneficiary will be notified that they are not responsible for reimbursing the providers for the recovered amount. To read transmittal 1209 go to: http://www.cms.gov/regulations-and-guidance/guidance/ Transmittals/Downloads/R1209OTN.pdf To read MLN Matters article MM8153 go to: http://www.cms.gov/outreach-and-education/medicare- Learning-Network-MLN/MLNMattersArticles/downloads/ MM8153.pdf Page 8
CMS Administrator s Ruling: Part A to Part B Rebilling for Denied Hospital Inpatient Claims On March 22, 2013 CMS issued Transmittal 1203 to implement the Administrator s Ruling which permits providers to re-bill inpatient Part A claims, denied by a Medicare contractor due to inpatient level of care not being medically necessary, to Part B payment of the full array of services provided without changing the patient s status. The patient s status must remain inpatient for this rebilling to take place. This is an interim policy that was established in CMS-1455-R and indicates that hospitals may submit a Part B inpatient claim for more services than those listed in section 10, Chapter 6 of the Medicare Benefit Policy Manual. Hospitals may submit a Part B inpatient claim for payment for the would have been payable had the beneficiary originally been treated as an outpatient rather than an inpatient, except for those services that are by Medicare definition, coding definition or by statue that specifically require an outpatient status. Part B inpatient and Part B outpatient claims that are filed later than 1 calendar year after the date of service shall not be rejected or denied as untimely by Medicare s claims processing system as long as the original corresponding Part A claim was filed timely. Hospitals will have 180 calendar days from the date of the receipt of the contractor s initial or revised determination of the Part A inpatient claim to submit Part B inpatient and/ or Part B outpatient claims. Hospitals submitting Part B inpatient claims subject to this interim policy mush have condition code W2. To read Transmittal 1203 go to: http://www.cms.gov/regulations-and-guidance/ Guidance/Transmittals/Downloads/R1203OTN.pdf To read MLN Matters Number MM8185, go to: http://www.cms.gov/outreach-and-education/ Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/MM8185.pdf Page 9
Revised and Clarified Place of Service (POS) Coding Instructions On March 29, 2013 CMS rescinded Transmittal 2613 dated December 14, 2012 and replaced it with Transmittal 2679 to indicate a clarification on the place of service for pathology and laboratory services. All other information will remain the same. Effective April 1, 2013, all POS codes used by physicians and other suppliers shall assign the same setting in which the beneficiary received the face-to-face service. Because a face-to-face encounter with a physician/practitioner is required for nearly all services paid under the Medicare Provider Fee Schedule and anesthesia services, this rule will apply to a majority of PFS services. They also add clarifying or special considerations provisions to Chapter 26 for POS code 15 mobile unit, POS code 17, walk-in rural health clinic, POS 22 hospital outpatient, POS 24 ASC and POS 34 hospice. Chapter 13 has been added to provide instructions for the PC or Interpretation and the TC of Diagnostic Tests pain under the MPFS. To read Transmittal 2679 go to: http://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/ R2679CP.pdf To read MLN Matters Number MM7631 go to: http://www.cms.gov/outreach-and-education/medicare-learning-network-mln/ MLNMattersArticles/Downloads/MM7631.pdf Page 10
On March 8, 2013, CMS released Transmittal 1196 to implement alert messaging effective April 1, 2013, to provide supplemental information to providers submitting claims for outpatient therapy from April 1, 2013 through June 2013. For therapy claims processed on and after April 1, 2013 through June 30, 2013 with dates of service on and after January 1, 2013, a Remittance Advice message will be provided to remind the provider to include the new functional limitation G codes, as well as the appropriate severity/complexity modifiers on future specified therapy claims. As a reminder beginning July 1, 2013 all claims that do not have the applicable G codes and severity/complexity modifiers will be returned or rejected to the provider. To read Transmittal 1196 go to: http://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/ R1196OTN.pdf To read MLN Matters Number MM8166 go to: http://www.cms.gov/outreach-and-education/medicare-learning-network-mln/ MLNMattersArticles/Downloads/MM8166.pdf Outpatient Therapy Functional Reporting Non-Compliance Alerts Page 11
April 2013 Update of the Ambulatory Surgical Center (ASC) Payment System CMS Transmittal 2662 issued March 1, 2013 with the April quarterly updates; the following is a summary of the changes contained in this transmittal. I. New Procedure Codes The following new has been added effective April 1, 2013: C9735 Effective Date 4/1/13 SI T APC 0150 Short Descriptor Long Descriptor ASC PI Anoscopy, submucosal inj Anoscopy; with directed submucosal injection(s, any substance G2 Page 12
II. Billing for Drugs, Biologicals, and Radiopharmaceuticals A. Drugs and Biologicals with Payments Based on Average Sales Price Effective April 1, 2013 Payments for separately payable drugs and biological based on ASPs are updated quarterly as the previous quarter s ASP submissions are available. The updated payment rates effective April 1, 2013 is contained in ASC Addendum BB and can be found at: http://cms.gov/medicare/medicare-fee-for-service-payment/ ASCPayment/11_Addenda_Updates.html B. Drugs and Biologicals with OPPS Pass-through Status Effective April 1, 2013 Below are the five drugs and biological that were granted ASC payment status effective April 1,2013. Code Long Descriptor ASC PI C9130* Injection, immune globulin (Bivigam), 500 mg K2 C9297* Injection, omacetaxine mepesuccinate, 0.01 mg K2 C9298* Injection, orciplasmin, 0.125 mg. K2 J7315 Mitomycin, ophthalmic, 0.2 mg K2 Q4127 Talymed, per square centimeter K2 Note: Codes with * indicate a new code effective April 1, 2013 C9298 Jetrea is packaged as a sterile single use vial containing 0.5 mg ocriplasmin in a 0.2mL solution for intravitreal injection. Use of the contents of an entire vial to one patient as per the FDA labeled approval would result in the reporting of 4 units of C9298 on a claim. J7315 Should only be used for Mitosol and not for the compounded mitomycin or other forms of mitomycin. Page 13
C. Flucelvax While Flucelvax (Influenza virus vaccine) was assigned a to CPT code 90661 since January 1, 2008 with a ASC payment indicator of Y5, it was not FDA approved until November 20, 2012. The ASC payment indicator has now been changed to L1 (Influenza Vaccine; Pneumococcal Vaccine) and will be reflected in the April 2013 ASC PI file. The table below provides the descriptors and new OPPS status indicator for CPT code 90661. D. Updated Payment Rates for Certain Codes Effective January 1, 2013 through March 31, 2013 The January 2013 ASC Drug File had the incorrect payment rates for codes J9263 and Q4106. The table below indicates the corrections that have been installed with the April 2013 update and is effective for services furnished on January 1, 2013 through March 31, 2013. Corrected Short Descriptor Payment Rate Code ASC PI APC J9263 K2 1738 Oxaliplatin $3.95 Q4106 K2 1245 Dermagraft $42.55 To read Transmittal 2262 please go to: http://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r2662cp.pdf To read MLN Matters MM8237 please go to: http://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/ Downloads/MM8237.pdf Page 14
Volume 13, Issue 2 April 25, 2013 155 Franklin Road Suite 100 Brentwood, TN 37027 Phone: 615-661-5145 Fax: 615-661-5147 E-mail: info@hmi-corp.com www.hmi-corp.com Website: www.hmi-corp.com CPT Copyright 2012 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. Q: What are the new modifiers that CMS has added to their listing? A: CMS has added two anatomical modifiers LM ( left main coronary artery) and RI (ramus intermedius coronary artery). These two modifiers can bypass NCCI edits when it is appropriate. CMS has also added two new modifiers that can bypass NCCI edits if appropriate for physician billing. The two new modifiers are 24 Unrelated E/M service by the same physician during a postoperative period and 57 Decision for surgery. http://www.cms.gov/medicare/coding/releasecodesets/alpha-numeric--items/2013- Alpha-Numeric-.html?DLPage=1&DLSort=0&DLSortDir=descending http://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/ downloads/mm8137.pdf Page 15